IS 


Columbia  toiberkitp  ^^ 
intijeCitpofJ^etoPorfe         \ 

College  of  ^Ijpgiciang  anb  burgeons 


Reference  Eibrarp 


CASE  HISTORIES 


IN 


MEDICINE 


ILLUSTRATING   THE   DIAGNOSIS.    PROGNOSIS   AND 
TREATMENT  OF  DISEASE 


BY 
RICHARD  C.  CABOT.  M.D. 

Assistant  Professor  of  Clinical  Medicine, 
Harvard  Medical  School 


Second  Edition,  Revised  and  Enlarged 


BOSTON 

W.  M.  LEONARD.  Publisher 
1912 


Copyright,  iqtt, 
By   W.  M.  Leonard. 

\'S\\ 

^  o  ■»  u      ^ 


PREFACE. 

Although  the  first  edition  of  this  book,  printed  without  an- 
swers to  the  questions,  was  for  undergraduate  use  only,  the  accom- 
panying teachers'  edition,  which  contained  answers  and  discussion, 
proved  of  interest  and  use  to  practitioners.  I  have  therefore  planned 
the  present  edition  with  practitioners  primarily  in  mind. 

To  present  medicine  in  terms  that  will  make  the  reader  work  —  to 
present  puzzles  like  those  which  confront  us  at  the  bedside,  and 
then  to  offer  at  the  end  of  each  case  my  own  solution  of  these 
puzzles  —  is  the  plan  pursued  in  this  as  in  the  last  edition.  We 
learn,  I  believe,  only  by  that  which'  makes  us  work,  not  by  any 
attempt  to  present  a  truth  as  a  free  gift. 

In  the  present  edition  I  am  less  limited  as  to  space  and  have 
therefore  gone  into  the  details  of  prognosis  and  treatment  —  what 
the  patient  and  his  family  want  —  more  thoroughly. 

I  have  changed  the  order  of  the  cases,  collecting  in  one  group 
those  dealing  with  the  heart,  in  another  those  concerning  the  lungs, 
etc.  I  have  also  added  a  number  of  cases,  bringing  the  total  num- 
ber up  to  one  hundred. 

Medical  teachers  are  often  charged  with  nihilism  in  therapeu- 
tics. To  refute  this  accusation  I  have  added  in  this  edition  a  list 
of  the  drugs  which  actually  are  used  by  the  internists  (most  of 
them  teachers)  attached  to  the  Massachusetts  General  Hospital  — 
a  list  very  similar,  I  think,  to  that  used  by  most  others  who  are 
popularly  supposed  to  scorn  drugs  altogether. 

I  hope  that  in  this  edition,  as  in  the  last,  I  shall  be  aided  by  the 
frank  criticism  of  those  who  differ  from  my  diagnoses,  my  prog- 
noses, or  my  therapeutics. 

190  Marlborough  Street,  November,  191 1. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/casehistoriesinmOOcabo 


TABLE    OF    CONTENTS. 


CHAPTER  I. 

INFECTIOUS  DISEASES. 
Case  No.  Page 

1.  Typhoid  Fever il 

2.  Pneumonia 15 

3.  Tuberculous  Peritonitis 18 

4.  Typhoid  Fever 19 

5.  Phthisis;  Typhoid;  Tuberculous  Enteritis 21 

6.  Phthisis;  Perforated  Gastric  Ulcer      27 

7.  Streptococcus  Sepsis , 34 

8.  Urinary  Sepsis 36 

9.  General  Miliary  Tuberculosis 39 

10.  Syphilitic  Aortitis 41 

11.  Tuberculous  Meningitis;  Generalized  Tuberculosis 43 

12.  Amoebic  Abscess  of  Liver 46 

13.  Tuberculous  Meningitis 48 

14.  Cerebral  Sj^philis 51 

15.  Phthisis 54 

16.  Cerebral  Syphilis 56 

17.  Alcoholism;  Syphilis 58 

18.  Malignant  Endocarditis 63 

19.  Empyema 66 

20.  Malignant  Endocarditis "  68 

21.  Left  Femoral  Phlebitis;  Pulmonary  Embolism 70 

22.  Appendicitis;  General  Peritonitis "^2 

23.  General  Peritonitis 76 

24.  Ludwig's  Angina  (Deep  Cervical  Abscess) 78 

25.  Suppuration  in  a  Uterine  Fibroid 81 

26.  Empyema  —  Rupturing  into  a  Bronchus      83 

27.  Epidemic  Cerebrospinal  Meningitis 86 

28.  Chicken-pox 89 

29.  Trichiniasis 91 

30.  Tertian  Malaria      94 

CHAPTER   II. 
DISEASES  OF   GASTRO-INTESTINAL  AND   BILIARY  TRACT. 

31.  Hepatic  Cancer;  Gastric  Cancer 97 

32.  Gastric  Cancer 100 

33.  Gastric  Cancer 102 

34.  Acute  Gastro-enteritis;  Fear  of  Appendicitis 104 

35.  Cancer  of  the  Hepatic  Flexure  of  the  Colon 106 

5 


6  TABLE   OF   CONTENTS. 

Case  No.  Page 

36.  Cancer  of  the  Splenic  Flexure  of  the  Colon 109 

37.  Cancer  of  the  Duodenal  Papilla      iii 

38.  Cirrhotic  Liver;  Haemorrhage  from  CEsophageal  Varices 113 

39.  Gall-stones 116 

40.  Fatty  Cirrhotic  Liver 119 

41.  Perforative  Cholecystitis 121 

42.  Cancer  of  the  Pancreas 123 

43.  Catarrhal  Jaundice 125 

44.  Duodenal  Ulcer      127 

45.  Gastric  Ulcer,  Perforation 129 

46.  Overeating 131 

47.  Gastric  Ulcer,  Perforation 133 

48.  Gastric  Ulcer,  Contracted  Stomach 135 

49.  Fecal  Impaction 137 

50.  Apprehension,  Constipation 139 

CHAPTER   HL 
DISEASES  OF  THE  URINARY  TRACT. 

51.  Irritable  Prostate •    •    •  143 

52.  Uraemia,  Chronic  Glomerulo-Nephritis 145 

53.  Chronic  Interstitial  Nephritis;  Cardiac  Hypertrophy  and  Dilatation  .  149 

54.  Hypernephroma 151 

55.  Amyloid  Kidney 153 

56.  Congenital  Cystic  Kidney;  Arteriosclerosis 156 

57.  Hypernephroma 158 

CHAPTER   IV. 
DISEASES  OF  THE  CIRCULATION. 

58.  Functional  Heart,  after  Typhoid 160 

59.  Myocarditis;    Weakness;    Acute  Dilatation  of  Heart;    Pulmonary 

(Edema 163 

60.  Myocardial  Weakness;  Arteriosclerosis 165 

61.  Mitral  Stenosis;  Cerebral  Embolism 169 

62.  Arteriosclerosis,  Cerebral  Haemorrhage 171 

63.  Athlete's  Heart 174 

64.  Stokes- Adams  Syndrome;  Coronary  Sclerosis 177 

65.  Angina  Pectoris;  Coronary  Sclerosis;  General  Arteriosclerosis     .    .  180 

66.  Aortic  Aneurism 183 

CHAPTER  V. 
RESPIRATORY  SYSTEM. 

67.  Pneumohydrothorax 185 

68.  Malignant  Disease  of  the  Lung 187 

69.  Cancer  of  the  Lung 189 

70.  Tracheitis;  Bronchial  Asthma      191 


TABLE   OF   CONTENTS. 


CHAPTER  VI. 

THE   NERVOUS  SYSTEM. 
Case  No.  Page 

71.  Cerebral  Arteriosclerosis 193 

72.  Tabes  Dorsalis;  Gastric  Crisis 196 

73.  Lead  Neuritis 199 

74.  Tabes  Dorsalis;  Gastric  Crisis 202 

75.  Alcoholism;  Alcoholic  Mania  and  Neuritis 204 

76.  Neuritis 207 

77.  Starvation;  Neurotic  Vomiting 209 

78.  Dynamic  Aorta 212 

79.  Traumatic  Neurosis 214 

80.  Functional  Tachycardia 217 

81.  Arteriosclerosis  (Shock) 221 

82.  Hysteria 223 

83.  Brain  Tumor 227 

84.  Apprehension      230 

85.  Eyestrain;  Maternal  Anxiety;  Urinal-Hyperacidity 232 

86.  Neurasthenia 234 

CHAPTER   Vn. 
DISEASES  OF  LYMPHATIC  AND   DUCTLESS  GLANDS. 

87.  Myxoedema 236 

88.  Myxoedema 238 

89.  Sarcoma  of  the  Praevertebral  Glands 240 

90.  Grave's  Disease      242 

91.  Diabetes  Mellitus 246 

92.  Inguinal  Neoplasm 251 

93.  Malignant  Disease  of  the  Thymus  Gland 253 

94.  Atrophic  Arthritis      255 

CHAPTER  VIII. 
DISEASES  OF  UNKNOWN  ORIGIN. 

95.  Secondary  Ansemia;  Cachectic  Purpura 257 

96.  Pernicious  Ansemia 261 

97.  Albuminuria  of  Adolescence 265 

98.  Aplastic  Ansemia 267 

99.  Pernicious  Ansemia 269 

100.    Lymphoid  Leucaemia 271 

CHAPTER  IX. 
NOTES  ON  DRUG  THERAPY. 

274 


CASE   HISTORIES 

IN 

MEDICINE. 


CHAPTER  I. 
INFECTIOUS   DISEASES. 

Case  I.  A  broker  of  twenty-six,  moderately  alcoholic,  but 
with  no  venereal  history.  Has  always  been  well.  Been  under 
a  surgeon's  care  for  last  three  days  for  "  grippe  "  and  taken 
whiskey  and  ammonol.  On  the  third  day,  Saturday,  he  took 
two  whiskies  and  went  to  ride.  The  horse  shied  and  threw  him. 
His  head  struck  on  a  rock,  just  above  and  in  front  of  the  right 
parietal  eminence.  Coma  for  ten  minutes ;  after  being  carried 
home  he  vomited  and  complained  of  pain  in  the  occiput  and 
numbness  of  the  right  hand.  Temperature  104°,  the  pulse 
90.  Next  morning  it  was  103°;  next  evening,  103.8°.  Monday 
it  was  102°,  pulse  85.  The  bowels  have  not  moved.  Patient 
has  regained  consciousness,  but  is  still  dazed.  There  is  no 
evidence  of  fracture  or  suppuration  anywhere,  but  there  is 
numbness  along  the  ulnar  side  of  the  right  hand. 

Seen  Tuesday;  very  bright,  sat  up  strongly  in  bed  to  shake 
hands.  Laughed  and  talked,  wanted  to  get  up,  but  tempera- 
ture still  102°. 

1.  What  are  the  objections  to  giving  ammonol  in  this  case? 

It  is  a  nostrum. 

2.  What  should  you  expect  to  find  in  this  patient's  urine? 

High  color  and  specific  gravity,  small  amount,  albumen 
a  trace,  a  few  hyaline  and  granular  casts. 

3.  What  facts  justify  the  statement:    "  There  is  no  evidence 

of  suppuration  anywhere  "?  That  the  classical  signs 
of  inflammation  (redness,  heat,  swelling,  tenderness 
and  pain)  are  absent;   that  leucocytosis  is  absent. 

Diagnosis:  The  coma,  the  occipital  pain  later  on,  the  vomit- 
ing, and  numbness  along  the  ulnar  side  of  the  right  hand, 
suggest  intracranial  trauma;  but  we  note  that  the  peripheral 
numbness  is  on  the  same  side  as  the  (supposed)  brain  injury. 
By  contrecoup  it  is  possible  to  injure  the  left  side  of  the  brain, 
but  hardly  possible  to  injure  the  cortical  area  corresponding 


12  CASE   HISTORIES    IN    MEDICINE. 

to  the  small  patch  of  peripheral  anesthesia.  The  absence  of 
lasting  coma,  paralysis,  or  obvious  injury  to  the  skull  make 
brain  injury  unlikely;  but  injury  to  the  exposed  ulnar  nerve 
is  natural  in  such  an  accident.  Fever  due  to  the  "  shaking 
up  "  of  the  accident  would  be  unlikely  to  reach  102°  four  days 
after.  "  Grippe  "  should  show  local  lesions  (of  the  respiratory 
tract  or  elsewhere),  and  rarely  causes  a  fever  reaching  102°  on 
the  seventh  day.  This  continued  fever,  without  obvious  local 
lesions,  should  naturally  suggest  (as  it  did  here)  a  Widal  test. 
This  proved  positive,  and  the  patient  went  through  an  attack 
of  typhoid  typical  except  for  the  absence  of  cerebral  symptoms 
or  marked  prostration. 

Prognosis :  The  younger  the  patient  the  better  the  prognosis 
in  typhoid,  other  things  being  equal.  Children,  for  example, 
almost  never  die  of  it.  At  the  age  of  this  patient,  the  general 
mortality  under  firstrate  conditions  of  treatment  is  about  six 
per  cent;  in  hospital  cases,  including  all  ages,  the  mortality 
averages  about  ten  per  cent.  The  favorable  influences  in  the 
present  case  are  as  follows: 

1.  He  has  been  put  to  bed  and  treatment  instituted  early 

in  the  course  of  the  disease.  He  has  not  used  up  his 
strength  by  performing  as  a  "  walking  typhoid." 

2.  There  is  no  evidence  of  any  complication  such  as  kidney 

trouble,  obesity,  arteriosclerosis,  or  any  of  the  influences 
which  make  people  unusually  vulnerable.  So  far  also 
we  see  none  of  the  acute  inflammatory  complications 
such  as  otitis  media,  parotitis,  or  phlebitis,  but  these 
may  make  their  appearance  later  on. 

3.  The  patient  is  quite  free  from  the  evidences  of  intense 

toxemia  such  as  are  often  seen  at  this  period  of  the 
disease.  There  is  no  mental  dullness,  no  twitching  of 
muscles  or  tendons,  no  special  rapidity  or  dicrotism 
of  the  pulse,  no  abdominal  distention,  no  delirium. 

4.  The  only  untoward  element  in  the  prognosis,  then,  is  his 

addiction  to  alcohol.  If  this  is  a  chronic  and  serious 
habit,  it  may  prove  a  genuine  handicap  in  his  struggle 
against  infection. 

Treatment:  Of  course  the  patient  must  be  kept  in  bed 
despite  his  desire  to  get  up.  Except  for  a  few  enthusiasts  in 
Philadelphia,  it  seems  to  be  universally  agreed  that  con- 
finement to  bed  during  the  febrile  period  is  best  in  cases  of 


INFECTIOUS   DISEASES.  I3 

typhoid  fever.  It  seems  to  be  unnecessary,  however,  to  insist 
that  the  patient  shall  never  raise  his  head.  There  is  no  harm 
in  his  sitting  up  now  and  then  for  examination  or  for  other 
purposes,  provided  no  strenuous  muscular  exercise  is  involved. 

The  diet  in  typhoid  is  now  rarely  as  disagreeable  for  the 
patient  as  it  used  to  be  fifteen  years  ago.  Very  few  physicians 
adhere  rigorously  to  the  old-fashioned  milk  diet  which  undoubt- 
edly produced  bulky  stools  and  might  well  be  supposed  to 
cause  as  much  local  irritation  in  the  intestine  as  any  diet  that 
could  be  selected.  The  important  principle  in  the  diet  of 
typhoid,  as  of  any  long-continued  fever,  is  to  avoid  substances 
that  call  for  hard  work  in  mastication,  and  also  to  keep  clear 
of  anything  which  is  specially  difficult  of  digestion.  In  other 
words,  we  feed  the  patient  according  to  his  digestive  power, 
avoiding  anything  that  is  difficult  to  chew.  This  plan  has  now 
been  successfully  followed  in  the  wards  of  the  Massachusetts 
General  Hospital  since  it  was  put  in  operation,  more  than  ten 
years  ago,  by  Dr.  Frederick  C.  Shattuck.  Patients  are  allowed 
soft  toast,  soft  boiled  eggs,  any  form  of  soup  or  broth,  finely  |L^l^ 
chopped  meat,  the  soft  part  of  baked  apple,  ice  cream,  custard,  L^ 
blanc  mange,  and  other  foods  of  similar  consistency.  They  '^ 
are  fed  six  times  a  day  and  once  or  twice  in  the  night,  depending 
upon  the  amount  of  sleep. 

Bathing  in  typhoid  is  also  far  less  uncomfortable  and  rigor- 
ous in  the  hands  of  most  clinicians  to-day  than  it  used  to  be, 
for  we  have  got  over  the  delusion  that  reduction  of  tempera- 
ture is  our  chief  goal.  A  bath  may  do  a  world  of  good  to  a 
patient  without  reducing  his  temperature  at  all,  because  it 
may  and  often  does  allay  his  nervous  restlessness,  procure 
quiet  sleep,  improve  his  appetite,  and  help  to  get  his  skin  in 
good  condition.  The  best  rule,  it  seems  to  me,  is  to  give  a  bath 
at  about  85°  F.  once  in  four  hours  whenever  the  temperature 
is  above  102.5.  Such  a  bath  should  be  accompanied  by  a  con- 
stant friction  of  the  skin  and  should  last  from  ten  to  twenty 
minutes,  depending  upon  the  quality  of  the  patient's  reaction 
to  it.  If  he  gets  blue  and  cold  at  any  time,  the  bath  should  be 
stopped.  It  can  be  given  in  bed  if  a  large  rubber  sheet  is  put 
under  the  patient  and  then  its  four  free  edges  raised  so  as  to 
make  a  shallow  cup  into  which  water  can  be  poured. 


14  CASE  HISTORIES   IN   MEDICINE. 

The  prevention  of  bedsores  is  best  accomplished  by  ab- 
solute cleanliness  of  the  skin,  a  smooth,  tight  under  sheet, 
frequently  changed,  and  especially  by  seeing  to  it  that  the 
patient  never  remains  for  more  than  two  hours  in  any  single 
position  such  as  brings  pressure  upon  the  sacrum,  the  shoulder 
blades,  the  hip  bones,  ankles,  or  heels. 

I  believe  that  something  can  be  done  to  prevent  otitis  media 
and  parotitis,  as  well  as  to  increase  the  patient's  comfort,  by 
washing  out  the  mouth  and  pharynx  with  any  simple  spray 
such  as  diluted  Dobell's  solution.  The  use  of  strong  antisep- 
tics is  unnecessary.  Such  a  cleansing  spray  should  be  used  at 
least  once  in  four  hours,  and  the  accumulations  of  sordes  about 
the  teeth  can  at  the  same  time  be  remoA^ed  with  a  cotton  stick. 

In  the  great  majority  of  cases  the  bowels  have  to  be  moved 
artificially.  An  enema  of  suds  every  second  day  is  the  best 
way  to  accomplish  this.  Even  with  this  we  sometimes  have  a 
troublesome  impaction  of  the  rectum  in  the  latter  weeks  of 
the  disease.  Cathartics  are  quite  unnecessary  and  sometimes 
harmful. 

Abdominal  distention  is  to  be  combated  by  the  use  of  the 
rectal  tube  and  by  hot  carminative  applications  such  as 
turpentine  stupes. 

Personally,  I  have  never  seen  any  good  come  of  the  use  of 
alcohol  in  typhoid  fever,  except  in  patients  who  were  unable 
to  take  other  food  in  any  considerable  quantity.  To  make 
up  such  a  deficiency  of  nutrition,  alcohol  may  have  considerable 
value.  For  the  circulatory  weakness  it  is,  I  believe,  useless. 
The  most  valuable  drug  for  sustaining  the  circulation  is,  I 
believe,  strychnia  given  subcutaneously  in  doses  of  about 
1-40  gr.  every  four  to  eight  hours  in  an  adult.    "^ 


INFECTIOUS   DISEASES.  15 

Case  2.  A  clerk,  married,  t^venty-four,  is  seen  Jan.  5.  His 
family  and  previous  history  and  habits  are  good.  He  went  to 
bed  the  night  of  the  3d  in  his  usual  health  and  slept  well. 
On  rising  in  the  morning  he  had  a  severe  chill,  but  went  to 
business.  After  an  hour  or  two  he  was  obliged  to  return  home, 
feeling  very  weak  and  aching  all  over.  He  took  to  his  bed, 
raised  some  bloody  sputum,  had  some  nosebleed,  and  passed 
urine  freely  without  pain,  but  containing  much  fresh  blood. 

When  seen  he  did  not  look  very  ill;  pulse  100,  respiration 
24,  temperature  103.6°.  He  complained  of  no  pain.  Physical 
examination  was  negative,  except  for  slight  dullness  with  feeble 
respiration  and  fine  rales  over  the  left  posterior  base  of  the  chest. 

There  were  several  discrete,  viscid,  tawny  sputa  in  a  cup. 
The  urine  was  smoky,  1014,  with  a  very  large  trace  of  albumen, 
urea  1.64%. 

The  sediment  contained  considerable  normal  and  alDnormal 
blood,  rather  numerous  epithelial  casts  of  large  diameter,  one 
disintegrated  blood  cast;  one  or  two  large,  fine  granular  casts. 

1.  What  diseases  are  apt  to  have  such  an  onset?     Meningitis, 

influenza,  septicemia,   tonsillitis  and  pneumonia. 

2.  W^hat   diagnostic   data   are   wanting?     The   twenty-four- 

hour  amount  of  uriae,  microscopic  examination  of  the 
sputum  and  of  the  blood. 

3.  What  conclusions  can  be  drawn  from  the  percentage  of 

urea?  No  conclusions  of  any  importance,  unless  the 
quantity  and  quality  of  the  patient's  diet  is  known 
and  controlled,  unless  we  know  the  twenty-four-hour 
amount  of  urine,  and  unless  we  can  exclude  such  in- 
fluences as  vomiting  and  diarrhea.  Obviously,  these 
conditions  are  not  often  possible. 

Diagnosis :  The  clinical  picture  is  that  of  an  infectious  fever 
with  signs  pointing  especially  to  the  left  lung  and  to  the  kid- 
neys. Tuberculosis  and  pneumonia  are  especially  to  be  con- 
sidered. As  the  hemoptysis  preceded  the  nosebleed,  it  is  not 
likely  that  all  the  blood  came  from  the  nose.  The  position 
of  the  pulmonary  signs  and  the  suddenness  of  onset,  with  chill 
and  general  pains,  are  much  more  characteristic  of  pneumonia 
than  of  tuberculosis.  The  absence  of  pain  on  the  second  day 
is  unusual  in  pneumonia,  but  by  no  means  unknown.    The 


1 6  CASE  HISTORIES    IN   MEDICINE. 

physical  signs  are  not  those  of  solidification,  but  are,  never- 
theless, just  such  as  are  often  seen  in  the  early  stages  of  pneu- 
monia. They  are  also  consistent,  however,  with  tuberculosis, 
and  only  by  the  course  of  the  case  and  by  repeated  examinations 
of  the  sputum  can  tuberculosis  be  excluded.  If  leucocytosis 
were  present  it  would  favor  the  diagnosis  of  pneumonia  as 
against  tuberculous  hemoptysis,  but  in  tuberculosis  pneumonia 
leucocytosis  also  occurs. 

Hematuria  without  pain  and  with  so  large  a  number  of 
casts  points  to  acute  nephritis.  Such  an  urine  is  decidedly 
characteristic  of  pneumococcus  infections  and  tends  to  support 
the  diagnosis  of  pneumonia  as  against  tuberculosis. 

Prognosis :  To  our  shame  we  must  admit  that  the  mortality 
from  pneumonia  is  about  the  same  as  it  was  half  a  century 
ago,  namely  from  15  to  25%  in  healthy  young  people,  and  from 
25  to  90%  in  the  alcoholic  or  the  aged.  I  will  mention  here 
some  influences  which  make  the  prognosis  worse  in  any  given 
case. 

1.  The    presence    of    any    complication    such    as    nephritis, 

acute  or  chronic,  delirium  tremens,  arteriosclerosis, 
diabetes  or  the  post-operative  state. 

2.  Any   evidence   of   extreme   toxemia,    such   as   abdominal 

extension,  delirium  or  stupor,  unusual  acceleration  of 
the  pulse  or  respiration,  grave  disturbance  of  digestion. 

3.  The  occurrence  of  thoracic  pain  so  severe  as  to  require 

morphia. 

4.  The  involvement  of  more  than  two  lobes.     This  latter 

condition  is  serious  not  because  of  the  diminution  of 
respiratory  area,  but  because  it  usually  indicates  an 
unusually  severe  general  infection  of  the  whole  body 
by  the  invading  organism. 

5.  As  has  already  been  suggested,  the  presence  of  alcoholism 

or  old  age  is  a  serious  handicap  to  any  patient  in  pneu- 
monia. 

Treatment:  i.  Many,  perhaps  most,  patients  are  more 
comfortable  in  the  upright  or  semi-upright  position,  and  it 
is  important  to  arrange  a  bed-rest  and  a  foot-brace  or  other 
support  so  that  the  patient  will  not  perpetually  be  sliding  down 
from  his  bed-rest  and  suffering  from  the  resulting  position 
and  from  his  attempts  to  raise  himself. 


INFECTIOUS   DISEASES.  1 7 

2.  As  in  typhoid  fever,  the  diet  should  be  planned  according 
to  the  patient's  digestive  power,  avoiding  such  substances 
as  need  much  chewing.  Some  patients  will  eat  almost  every- 
thing that  they  are  accustomed  to  take  in  health,  and  be  the 
better  for  it.  Others  will  refuse  everything  but  liquids,  and 
take  but  little  of  these.  In  any  case,  food  should  be  offered 
to  the  patient  at  least  once  in  three  hours,  and  an  abundance 
of  water  should  be  given  him  with  the  least  possible  exertion 
on  his  part.  The  exercise  necessary  to  procure  a  movement 
of  the  bowels  is  sometimes  precarious  for  a  patient  suffering 
from  pneumonia.  All  that  we  can  do  is  to  diminish  such 
exertion  by  every  means  in  our  power.  In  some  patients  the 
objection  to  the  use  of  a  bedpan  is  so  strong  that  it  is  actually 
easier  for  them  if  they  are  allowed  to  get  out  of  bed  and  use 
a  commode  placed  close  at  hand.  By  laxatives,  such  as  arti- 
ficial Carlsbad  salts  or  sodium  phosphate  perhaps  supple- 
mented by  a  small  enema,  we  may  prevent  the  patient  from 
having  to  strain  at  stool. 

3.  Pain  in  the  chest  is  often  relieved  and  sometimes  alto- 
gether abolished  by  the  use  of  a  tight  chest  swathe,  which 
should  reach  from  the  armpit  to  the  waist  line,  and  should  be 
put  on  so  tight  that  at  first  the  patient  complains  of  it.  It 
should  be  loosened  in  case  he  still  finds  it  uncomfortable  in 
fifteen  minutes. 

4.  Fresh  cold  air,  such  as  can  be  obtained  by  putting  the 
patient  close  to  an  open  window  or  actually  out  of  doors,  is  of 
great  benefit.  We  must  be  careful,  of  course,  that  the  surface 
of  the  body  is  not  chilled,  but  with  good  nursing  this  is  easily 
arranged.  I  have  never  seen  any  benefit  from  oxygen  given 
from  a  can.  The  only  drugs  that  I  have  seen  of  benefit  are 
strychnia  and  morphia.  Strychnia  is  most  useful  when  re- 
served until  the  pulse  rises  above  120,  or  until  it  becomes 
irregular.  It  is  far  more  effective  given  subcutaneously,  be- 
ginning with  the  fortieth  of  a  grain  every  four  hours,  and 
increasing  to  a  thirtieth  or  even  a  twentieth.  Morphia  is  to 
be  used  only  when  pain  is  such  as  to  render  it  imperative. 
It  is  best  given  subcutaneously  in  I  gr.  doses,  and  accompanied 
by  I -120  of  atropia. 


1 8  CASE  HISTORIES   IN    MEDICINE. 

Case  3.  Young  salesman,  always  well  till  present  illness. 
Family  history  good.  Worked  hard  last  winter  and  worried. 
Frequent  headaches,  indigestion,  insomnia.  Feeling  poorly 
for  several  weeks,  especially  at  end  of  day,  but  has  worked 
until  week  ago;  since  then,  on  sofa  and  in  bed.  Chief  com- 
plaints, weakness  and  pain  in  left  chest.  Two  chills  this  week ; 
slight,  dry  cough;  no  nosebleed.  Bowels  constipated  and 
appetite  poor. 

Physical  examination:  Fairly  nourished,  tongue  coated, 
expression  bright,  no  enlarged  glands.  Heart  shows  musical 
systolic  murmur  at  apex,  heard  in  axilla  and  back;  action 
slightly  irregular;  no  enlargement.  Pulmonic  second  sound 
normal.  Lungs  negative,  except  over  seat  of  pain  in  side, 
where  was  heard  a  harsh  sound  synchronous  with  respiration 
for  a  few  breaths  and  then  not  heard  again.  Abdomen 
shows  dullness  in  both  flanks,  which,  however,  shows  but 
little  shift  with  change  of  position.  Liver  dullness  from 
sixth  rib  to  rib-margin.  The  spleen  is  not  palpable,  splenic 
area  tympanitic,  knee  jerks  lively.  Temperature,  99-102°, 
swinging  up  in  the  afternoon.  Pulse,  loo-iio.  No  sputa. 
Urine  negative. 

Blood  examination:  Reds,  3,200,000;  whites,  4,000;  Hb., 
40%. 

1.  When    a    patient's    chief    complaint    is    weakness,    what 

diagnoses  should  be  considered?  Anemia,  bad  hygiene, 
typhoid,  nephritis,  endocarditis,  myxedema,  tubercu- 
losis. 

2.  Name  five  common  causes  of  pain  in  the  left  axilla.     Dys- 

pepsia, pleurisy  {"  simple,"  pneumonic,  tuberculous), 
intercostal  neuralgia,  muscular  pain,  hypertrophic 
spondylitis. 

3.  How  should  the  cardiac  murmur  be  interpreted  in  this 

case?  Musical  murmurs,  widely  transmitted,  usually 
mean  endocarditis  (acute  or  chronic) ,  but  in  the  absence 
of  any  demonstrable  cardiac  enlargement  or  accentua- 
tion of  the  pulmonic  second  sound,  the  murmur  may 
possibly  be   "  functional."     Suspend  judgment. 

4.  What  adventitious  thoracic  sounds  are  most  likely  to  be 

fugitive,  as  In  this  case?  Rales,  especially  musical 
rales,  friction  sounds,  pleural  or  pericardial. 

5.  Significance  of  the  leucocyte  count  in  this  case?     It  makes 


INFECTIOUS   DISEASES.  I9 

septic  endocarditis  or  any  other  form  of  sepsis  very 
unlikely. 
6.  General  significance  of  normal  or  subnormal  leucocyte 
counts  ?  Their  presence  in  typhoid  and  malaria  makes 
them  very  valuable  in  cases  where  either  of  these  diag- 
noses is  being  balanced  against  a  possible  pneumonia, 
meningitis,  or  septicaemia.  Primary  anaemias  have  nor- 
mal or  subnormal  leucocyte  counts;  some  secondary 
anaemias  show  leucocytosis.  Most  cases  of  abscess  (ap- 
pendix, liver,  etc.)  raise  the  leucocyte  count.  Most 
cases  of  cancer  and  uncomplicated  tuberculosis  do  not. 

Diagnosis :  Continued  fever  with  chills,  anaemia,  signs  sug- 
gesting endocarditis  and  dry  pleurisy,  possibly  fluid  in  the 
peritoneum,  and  a  low  leucocyte  count  are  the  essentials  of 
this  case.  Typhoid,  malignant  endocarditis  (with  or  with- 
out a  primary  focus  elsewhere),  malaria,  and  tuberculosis 
(pleural,  peritoneal)  are  especially  to  be  considered.  The 
question  of  malaria  can  be  settled  by  blood  examination. 
Neither  malaria  nor  typhoid  will  account  for  the  physical 
signs  in  the  chest  or  abdomen.  The  Widal  reaction  should 
be  tried.  Against  septic  endocarditis  is  the  leucocyte  count 
and  the  absence  of  embolic  phenomena.  Blood  cultures 
should  be  made.  In  favor  of  tuberculosis  are  the  physical 
signs  (apparently)  of  dry  pleurisy  and  of  fluid  in  the  belly 
(perhaps  prevented  by  adhesions  from  shifting).  This  diag- 
nosis was  further  supported  by  the  negative  blood  cultures, 
the  absence  of  a  Widal  reaction,  and  of  malarial  parasites. 
Operation  showed  it  to  be  correct. 

Prognosis:  About  half  of  the  recognized  cases  recover, 
some  with,  some  without  operation.  A  large  number  of 
others  probably  recover  without  ever  being  diagnosed. 
Such,  at  any  rate,  is  the  suggestion  of  many  post  mortem 
examinations. 

Features  which  make  the  prognosis  worse  than  the  average 
are  as  follows: 

(i)  Steady  fever  not  improved  by  a  rest  in  bed. 

(2)  Marked  emaciation  and  lack  of  appetite. 

(3)  Intractable  diarrhoea. 

(4)  Marked  anaemia. 

(5)  The  demonstrable  presence  of  tuberculosis  elsewhere. 


20  CASE  HISTORIES   IN  MEDICINE. 

Treatment:  No  one  is  wise  enough  to-day  to  decide 
whether  medical  or  surgical  treatment  gives  the  patient  the 
better  chance.  Many  cases  have  recovered  under  either 
method.  As  a  rule  the  worst  cases  receive  surgical  treat- 
ment while  the  milder  ones  receive  only  hygienic  and  tonic 
treatment.  This  makes  all  comparison  and  statistics  unre- 
liable. 

Hygienic  measures  should  be  tried  first.  Under  rest  in 
bed  and  forced  feeding,  the  fever  and  other  constitutional 
symptoms  may  abate  and  the  fluid  disappear.  The  latter 
change  is  favored,  however,  in  some  cases  by  tapping. 

The  measures  just  suggested  are  more  effective  if  the  patient 
can  be  put  outdoors  and  treated  exactly  like  a  case  of 
phthisis.  Drugs  and  local  applications  have,  in  my  creed, 
no  value  if  we  leave  out  of  account  such  appetizers  as  gentian 
and  nux  vomica. 

I  think  that  in  all  cases  the  abdomen  should  be  tapped 
when  fluid  is  known  to  be  present. 

If,  after  five  or  six  weeks  of  this  kind  of  treatment,  no 
improvement  is  noted,  laparotomy  may  be  advised,  but  this, 
too,  should  be  followed  up  by  outdoor  life  and  all  the  hy- 
gienic measures  ordinarily  associated  with  the  care  of  con- 
sumption. 


INFECTIOUS   DISEASES.  21 

Case  4.  February  i6  a  lady  of  thirty,  married  eight  years, 
is  seen  in  consultation.  She  has  had  four  children,  the  young- 
est four  months  old.  After  her  second  confinement  had 
puerperal  septicaemia.  The  catheter  was  used  and  cystitis 
apparently  followed,  as  the  bladder  was  irrigated.  Vesical 
symptoms  were  troublesome  after  this,  and  five  separate 
times  she  underwent  prolonged  treatment  under  an  eminent 
gynaecologist.  Finally,  discouraged  by  the  persistence  of  her 
symptoms,  she  resorted  to  "  mind  cure,"  with  marked  relief. 
Her  last  confinement  was  easy,  but  was  followed  by  a  return 
of  vesical  symptoms.  For  the  last  six  weeks  she  has  suffered 
from  indigestion  and  has  had  frequent  watery  stools,  pre- 
ceded by  abdominal  pain.  January  23  she  came  to  Boston, 
and,  acting  on  the  advice  of  her  "  mind  cure  "  friend,  shopped, 
went  to  the  theater,  and  was  generally  very  active.  During 
this  treatment  she  ate  scarcely  anything,  and  at  the  end  of 
five  days  returned  home.  The  next  day  vomiting  appeared, 
and  by  February  i  the  stomach  retained  nothing.  The  vom- 
iting ceased  within  two  days  and  has  not  since  recurred.  The 
bowels  have  continued  loose,  moving  two  to  five  times  daily 
without  notable  pain.  For  two  weeks  there  has  been  some 
cough,  with  little  or  no  expectoration.  Since  February  i, 
pyrexia  has  been  constant,  —  as  a  rule,  higher  at  night, 
though  sometimes  higher  in  the  morning,  ranging  between 
101°  and  104°.  The  pulse  has  ranged  between  no  and  140. 
No  delirium. 

The  hands  are  clammy,  the  color  of  the  face  good,  the  eye 
bright,  the  mind  clear,  the  knee-jerks  lively.  The  chest  and 
abdomen  are  negative,  except  for  medium  rales  at  both  bases 
and  moderate  tenderness  along  the  colon.  The  urine  is  said 
to  be  negative.  It  is  stated  that  she  is  a  very  reticent  person 
and  has  never  been  known  to  be  hysterical. 

Diagnosis:  The  patient  has  been  well  for  four  years. 
Hence  there  is  no  reason  for  connecting  the  puerperal  sepsis 
or  cystitis  with  the  present  symptoms.  She  suffers  now  from 
continued  fever  (which  has  lasted  certainly  sixteen  days  and 
probably  more),  diarrhoea,  with  slight  general  abdominal  ten- 
derness and  dry  cough  (with  rales  at  both  bases).  The  con- 
dition of  the  blood  Is  unknown.     In  New  England  there  are 


22  CASE   HISTORIES   IN   MEDICINE. 

three  common  causes  of  long-continued  fever:  general  sepsis 
(including  septic  endocarditis),  tuberculosis,  and  typhoid;  less 
common  are  syphilis  and  sestivo-autumnal  malaria.  The 
month  and  the  place  make  malaria  unlikely.  (Blood  exami- 
nation ruled  it  out.)  Syphilis  should  show  some  lesions,  with 
or  without  a  history  of  its  origin.  Such  lesions  and  history 
were  absent  here.  There  were  no  local  signs  of  tuberculosis 
or  of  a  septic  focus,  but  as  either  of  these  diseases  may  exist 
without  local  signs  the  most  Important  evidence  in  this  case 
should  be  sought  in  the  blood.  This  showed  a  Widal  reac- 
tion and  no  leucocytosis.  The  subsequent  course  was  that 
of  typhoid,  without  the  classical  mental  dulness. 
Prognosis  and  Treatment  (see  above,  Case  i.) 


INFECTIOUS   DISEASES.  23 

Case  5.  A  manufacturer,  thirty- five  years  old,  is  seen 
May  28.  His  father  and  sister  died  of  phthisis,  otherwise 
the  family  history  is  negative.  While  -never  strong  he  has 
been  able  successfully  to  attend  to  a  large  and  exacting  busi- 
ness. Three  years  ago  he  suffered  from  sestivo-autumnal 
malaria.  Since  then  he  has  been  treated  several  times  for 
malaria.  Last  December  he  began  to  feel  run  down,  but 
kept  at  work  until  the  latter  part  of  March,  when  he  went 
South  to  recuperate  and  remained  there  two  weeks.  His 
appetite  and  strength  improved,  but  on  his  return,  April  8, 
after  an  elaborate  dinner,  he  complained  of  nausea  and  fiatu- 
lenc^^  and  felt  feverish.  He  went  to  bed  where  he  has  since 
remained.  He  has  vomited  occasionally,  and  has  had  a  half 
dozen  loose  movements  a  day,  nearly  black  in  color,  probably 
the  result  of  bismuth  which  he  has  taken  frequently.  During 
the  last  three  days  he  has  noticed  a  slight  dry  cough.  The 
temperature  chart  shows  a  wavelike  curve.  Every  nine  or 
ten  days  the  morning  temperature  is  normal,  where  it  re- 
mains for  from  one  to  four  days.  It  then  gradually  rises  for 
four  or  five  days  to  102°  or  103°,  and  as  gradually  falls.  The 
evening  record  follows  the  morning  curve  closely,  but  has 
rarely  gone  below  100°.  The  temperature  Is  always  higher 
at  night,  and  often  during  the  periods  of  morning  apyrexia 
rises  as  high  as  103°.  He  has  lost  greatly  in  strength  and 
flesh. 

Physical  examination  shows  a  man  much  emaciated  and 
weak.  Sensorium  free.  Both  cheeks  are  slightly  flushed. 
There  is  dulness  over  the  left  front  down  to  the  third  rib  and 
in  the  left  supraspinous  region,  with  bronchovesicular  respi- 
ration, increased  voice  sounds,  and  numerous  high-pitched, 
moist  rales  at  the  end  of  inspiration.  The  heart  sounds  are 
normal.  The  hard,  smooth  edge  of  the  spleen  is  felt  two 
inches  below  the  ribs.  The  liver  is  normal.  The  abdomen  is 
distended,  tympanitic,  somewhat  tender  everywhere,  espe- 
cially in  the  right  iliac  fossa.  Pulse  112,  weak  and  thready. 
Respiration  24.  Leucocytes  12,000.  Widal  reaction  positive  in 
dilution  1-60,  but  not  higher.  Blood  culture  shows-no  growth. 
Examination  of  the  stools  showed  bacillus  of  tuberculosis,  B. 
typhosus,  B.  coli  communis,  streptococcus  pyogenes,  staph- 


24  CASE  HISTORIES   IN   MEDICINE. 

ylococcus  pyogenes  albus.  Urine  1018,  acid,  slight  trace 
of  albumin,  a  few  hyalin  and  fine  granular  casts,  amount 
60  ounces. 

1.  How  can  the  lung  signs  be  explained  in  view  of  the  fact 

that  there  has  been  but  three  days'  cough  and  no  sputa  ? 
Acute  phthisis  may  produce  no  cough  or  sputa;  the 
same  is  true  of  pneumonia,  but  the  picture  is  more  like 
phthisis. 

2.  Would  further  tests  help  the  diagnosis?     No;  the  data 

given  are  sufficient. 

3.  How  do  you  interpret  the  Widal  reaction  in  this  case  ? 

As  evidence  of  typhoid. 

Diagnosis:  Tuberculosis  and  typhoid  are  proved  by  the 
data  in  the  stools. 

Prognosis:  The  prognosis  and  treatment  of  typhoid  fever, 
one  of  the  two  maladies  from  which  this  patient  is  suffering, 
have  already  been  given  in  the  discussion  of  Case  i.  I  will 
discuss  here  the  prognosis  and  treatment  of  phthisis. 

The  outlook  depends  above  all  upon  the  patient's  temper- 
ament —  that  is,  upon  the  amount  of  courage  and  patience 
which  he  can  muster  in  response  to  the  call  for  a  long,  disap- 
pointing, and  most  tedious  illness.  It  is  almost  useless  to 
undertake  the  costly  and  intricate  campaign  by  which  alone 
a  patient  may  be  saved,  unless  the  patient  possesses  or  can 
be  easily  roused  to  manifest  a  spirit  of  determination,  docility, 
and  perseverance. 

Next  to  the  patient's  character,  his  income  is  the  most 
important  factor  in  relation  to  his  recovery.  Taking  it  by 
and  large,  consumption  is  curable  in  the  rich,  incurable  in 
the  poor,  while  in  the  moderately  well-to-do  the  chances  are 
proportionately  intermediate.  Each  of  the  essentials  of 
treatment  is  costly.  Neither  rest,  fresh  air,  nor  food  can  be 
had  without  considerable  expense,  and  the  convalescence  is 
almost  as  expensive  as  the  acuter  phases  of  the  disease. 

Next  to  character  and  income  the  most  important  deter- 
mining factor  is  the  family  history.  If  a  parent  or  near  rela- 
tive has  shown  great  capacity  to  resist  the  disease  and  to 
transform  it  into  the  chronic  so-called  "  old-fashioned  "  type 
of  consumption,  there  is  some  ground  for  expecting  that  the 


INFECTIOUS   DISEASES.  25 

patient  will  show  the  same  qualities  which  under  the  title  of 
"  diathesis  "  or  "  constitution  "  have  long  been  recognized 
as  of  great  importance. 

The  amount  of  lung  involved  is,  if  other  conditions  are 
equal,  a  very  fair  measure  of  the  severity  of  the  case.  Never- 
theless there  are  persons  whose  powers  of  resistance  are 
such  that  despite  an  extensive  involvement  of  both  lungs  they 
get  along  much  better  than  many  so-called  incipient  cases. 
Even  some  of  the  third-stage  cases  make  complete  and 
lasting  recoveries,  while  some  of  the  incipient  ones  cannot  be 
checked. 

More  important  in  prognosis  is  the  severity  or  mildness 
of  constitutional  symptoms  indicating  the  amount  of  second- 
ary infection  by  pyogenic  organisms.  Rapid  pulse,  high 
fever,  quick  respiration,  sweating  during  sleep,  emaciation, 
dilated  pupils  are  among  the  most  threatening  and  unfavor- 
able of  all  the  signs  of  phthisis.  Even  a  rapid  pulse  without 
any  of  the  others  of  this  group  is  a  bad  prognostic  sign. 

The  larger  the  amount  of  sputum  and  the  more  numerous 
the  bacilli  contained  in  it,  the  worse  the  outlook. 

The  condition  of  the  patient's  digestion  before  the  onset 
of  the  disease,  his  liability  to,  or  freedom  from  digestive 
troubles,  the  reliability  of  his  appetite  and  presence  or 
absence  of  a  finicky  disposition  in  relation  to  certain  staple 
foods,  such  as  milk,  eggs,  bread,  or  meat,  are  important  fac- 
tors as  regards  that  maintenance  of  nutrition  which  is  an 
absolute  essential  for  successful  treatment. 

Pulmonary  haemorrhage,  occurring  early  in  the  course  of 
the  disease,  seems  to  me  to  have  very  little  prognostic  sig- 
nificance. This  may  also  be  true  of  haemorrhage  occurring 
later  in  the  development  of  the  malady,  but  one  not  infre- 
quently finds  that  haemorrhage  in  an  advanced  case  leads 
straight  to  acute  tuberculous  pneumonia,  and  so  to  a  fatal 
termination.  Patients  practically  never  die  from  loss  of 
blood,  and  this  fact  is  one  which  should  always  be  made 
known  to  them,  as  it  has  great  power  to  reassure. 

Finally,  I  may  mention  the  obviously  grave  significance  of 
foci  of  tuberculosis  in  other  parts  of  the  body  such  as  the 
genito-urinary  tract    or    the    bones.     A    complication    with 


26  CASE   HISTORIES   IN    MEDICINE. 

laryngeal  tuberculosis  renders  phthisis  almost  invariably 
fatal.     Nevertheless  there  are  exceptions  to  this  rule. 

Treatment:  Everyone  knows  that  the  essentials  for  the 
consumptive  are  food,  rest,  and  fresh  air.  Our  problem  is  to 
furnish  these  in  the  most  available  form. 

The  patient  should  be  told  at  the  start  that  he  will  be 
unable  to  work  for  at  least  a  year  and  that  this  period  may 
very  likely  be  prolonged  to  two,  three,  or  even  more  years. 
He  should  further  be  made  to  understand  that  he  is  strug- 
gling with  a  life-long  foe  against  whom  he  has  need  of  eternal 
vigilance.  Hygienic  indiscretions  such  as  the  sound  man 
can  commit  with  impunity,  may  at  any  time  be  followed 
in  the  tuberculous  patient  by  the  return  of  all  his  old  symp- 
toms. There  is  no  such  thing  as  cure,  in  the  sense  that  a 
broken  leg  may  be  cured.  The  disease  tends  perpetually  and 
in  all  cases  toward  relapse,  and  it  is  only  by  watchful  care 
and  ideal  hygienic  habits  that  this  tendency  can  be  kept  in 
check. 

The  general  public  and  a  considerable  number  of  phy- 
sicians have  never  learned  that  the  fresh  air,  so  essential  to 
a  tuberculous  patient,  should  be  obtained  without  exercise. 
Exercise  is  bad  for  the  tuberculous  patient  throughout  the 
larger  portion  of  his  disease,  and  especially  In  the  earlier 
stages  of  treatment.  Absolute  rest  In  the  open  air  Is  what  we 
want  and  It  must  be  confessed  that  it  Is  a  very  hard  thing  to 
get.  "  Cot  duty,"  the  laborious  wasting  of  one's  time  upon 
a  cot  or  In  a  steamer  chair  outdoors,  is  the  task  to  which  we 
must  strive  to  accustom  our  patients.  Only  a  few  minutes 
each  day  should  be  spent  within  the  house.  Some  physicians 
believe  that  It  Is  of  great  importance  to  keep  the  head  low 
and  therefore  compel  their  patients  to  absolute  recumbency. 

Sleeping  in  the  open  air  must  be  distinguished  from  lying 
awake  in  the  open  air.  If  a  night  out-of-doors  means  wake- 
fulness with  constant  dread  of  bats,  bears,  and  burglars,  it 
is  obviously  Inferior  to  a  good  night's  sleep  within  the  house; 
but  If  sleep  can  be  obtained  out-of-doors  It  is  probably  more 
beneficial  because  of  the  moving  currents  of  air  which, 
especially  in  summer,  can  rarely  be  obtained  Indoors. 

The  art  of  sleeping  out-of-doors  in  cool  weather  is  chiefly 


INFECTIOUS   DISEASES.  27 

a  matter  of  dressing  properly  for  bed.  The  head  and  neck 
must  be  covered  by  a  knitted  hood,  or  an  extra  wrap  of  some 
kind,  drawn  down  so  that  only  the  tip  of  the  nose  projects. 
Hot-water  bags  or  hot  soapstones  are  often  useful.  In  any 
event  the  patient  must  not  feel  cold. 

Some  persons  are  prevented  from  getting  their  proper  sleep 
during  the  morning  hours  because  they  are  awakened  by  the 
early  light.  This  may  be  excluded  by  tying  over  the  eyes 
a  soft,  black  silk  cloth  which  Is  kept  at  hand  and  tied  on  at 
the  very  first  waking  in  the  early  morning.  One  soon  ac- 
quires the  habit  of  adjusting  this  blinder  without  staying 
awake  more  than  a  minute  or  two.  The  association  of  its 
presence  and  Its  pressure  over  the  eyes  with  the  act  of  going 
to  sleep  soon  come  to  make  it  a  valuable  hypnotic  during  any 
daytime  nap  as  well  as  In  the  early  morning  light. 

To  make  up  for  the  tissue  destruction  due  to  fever  and 
toxaemia,  the  patient  must  be  taught  to  take  an  excess  of 
nutrition.  All  types  of  food  are  of  value.  There  Is  no  special 
virtue  in  taking  an  extraordinary  quantity  of  meat,  milk,  or 
raw  eggs,  though  these  last  two  foods  are  convenient  because 
they  can  be  taken  without  cooking  and  at  any  time  of  the 
day,  and  because  of  the  considerable  amount  of  fat  which 
they  contain.  There  Is  no  advantage  In  making  the  patient 
obese  —  Indeed  an  excess  of  fat  may  bring  a  harmful  strain 
upon  the  heart,  which  is  usually  more  or  less  weakened  In  all 
tuberculous  infections.  The  habit  of  taking  six  meals  a  day 
Is  one  that  most  patients  easily  fall  into,  as  people  do  on  ship- 
board or  whenever  they  have  nothing  else  to  do. 

Occupation  represents  an  Important  and  difficult  problem, 
for  anything  that  Involves  much  use  of  the  muscles  or  any 
strenuous  mental  effort  is  likely  to  produce  fever  and  check 
the  progress  of  the  patient's  recovery.  On  the  other  hand, 
absolute  Idleness  often  leads  to  depression  and  restlessness. 
Light  manual  and  mental  tasks  must  be  devised  and  prescribed 
in  small  doses  with  frequent  rests. 

In  convalescence,  after  the  fever  has  disappeared,  muscular 
work  is  apt  to  be  of  distinct  benefit  both  for  the  encourage- 
ment which  It  gives  and  for  the  benefit  to  nutrition  and  cir- 
culation.    Possibly,  also,  it  may  serve  to  wash  into  the  general 


28  CASE   HISTORIES   IN   MEDICINE. 

circulation  a  small  amount  of  the  patient's  own  tuberculin 
and  thus  to  increase  his  immunity. 

Last,  but  not  least,  it  should  be  clearly  understood  that  no 
patient  is  likely  to  finish  his  recovery  without  several  changes 
of  climate  and  environment.  The  good  that  is  done  by  a 
new  climate  is  due  largely  to  the  fact  that  it  is  new.  Mind 
and  body  alike  are  stimulated  and  benefited  by  the  change. 
Three  or  four  months  in  one  place  are  usually  enough. 

Drugs  are,  in  my  opinion,  of  no  value  except  to  combat 
such  symptoms  as  anorexia  or  constipation.  I  have  seen  no 
advantage  from  any  medication  for  the  treatment  of  haemor- 
rhage and  rarely  any  from  the  treatment  of  cough,  though 
2V  o^  tV  grain  of  heroin  is  occasionally  useful  given  every  four 
hours  for  an  irritating  and  unproductive  cough. 


INFECTIOUS   DISEASES.  29 

Case  6.  A.  R.,  aged  fifty,  was  seen  June  3.  He  had  always 
been  troubled  with  constipation,  his  bowels  moving  only  once 
or  twice  a  week.  For  five  weeks  he  had  had  epigastric  pain, 
which  for  three  days  had  been  severe.  He  had  had  no  move- 
ment of  the  bowels,  no  chills,  or  fever. 

Physical  examination  showed  a  thin,  worn-looking  man. 
The  pulse  and  temperature  were  normal,  the  tongue  clean 
and  moist.  His  chest  showed  diminished  breathing  through- 
out the  left  chest,  bronchovesicular  respiration  and  dulness 
at  the  right  apex,  and  numerous  rales  throughout  this  side. 
The  abdomen  was  distended.  There  was  dulness  in  the  left 
hypochondrium,  with  marked  tenderness  and  muscular  spasm. 
Elsewhere  the  belly  was  tympanitic. 

A  high  enema  relieved  him  of  large  masses  of  scybala  and 
made  him  more  comfortable,  but  on  June  10  there  was  still  a 
tender  mass  in  the  left  hypochondrium.  Temperature  99.6°, 
pulse  90. 

1.  In  what  way  and  to  what  extent  should  the  patient's  age 

and  the  condition  of  his  chest  influence  our  decision  as 
to  an  operation  ?  The  signs  are  strongly  suggestive  of 
phthisis;  if  this  is  confirmed  by  sputum  examination, 
the  risks  of  anaesthesia,  especially  in  a  man  of  fifty,  are 
considerable.  Nevertheless,  the  risk  of  not  operating 
may  be  greater. 

2.  What  is  a  high  enema?     How  and  with  what  materials 

should  it  be  given  ?  A  high  enema  is  one  which  reaches 
above  the  rectum  for  a  greater  or  smaller  distance.  It 
should  be  given  with  soft  rubber  tube  passed  up  as 
high  as  it  will  go,  with  the  patient  on  his  left  side  and 
the  hips  raised.  Warm  suds  preceded  by  warm  oil  may 
be  used. 

3.  Importance  of  the  temperature  and  pulse  here?     If  they 

remain  low  and  without  leucocytosis,  the  danger  of 
spreading  peritonitis  or  of  active  abscess  Is  not  great. 

4.  What  other  data  should  be  known  ?     The  condition  of  the 

sputa,  blood,  urine,  arteries,  and  heart. 

Diagnosis :  Dulness,  tenderness,  and  spasm  in  left  hypochon- 
drium unrelieved  by  high  enemata,  point  to  a  localized  peri- 
tonitis. This  might  be  excited  by  ulcer  or  cancer  6f  the 
stomach  or  colon,  or  by  abscess  of  the  spleen  (very  rare). 
The  Intestinal  symptoms  are  not  as  marked  as  they  are  apt 


30  CASE  HISTORIES   IN   MEDICINE. 

to  be  when  ulcer  or  cancer  of  the  colon  have  passed  their  long 
period  of  latency  and  make  themselves  felt.  The  stomach 
seems  likely  to  be  the  source  of  the  peritonitis,  but  further 
than  this  we  cannot  go.  Ulcer  is  more  apt  to  perforate  than 
cancer,  but  cancer  is  commoner  at  this  age. 

Operation  showed  a  perforation  of  the  anterior  wall  of  the 
stomach  near  the  cardia,  with  adhesions  to  the  abdominal 
wall.     No  pus  or  general  peritonitis. 

Phthisis  was  proved  by  the  sputum  examination. 

Prognosis:  Only  the  prognosis  and  treatment  of  peptic 
ulcer  will  be  here  discussed. 

First,  as  regards  duration,  we  know  that  the  average  history 
of  peptic  ulcer  covers  many  years  of  moderate  inconvenience 
or  suffering  without  actual  disability.  This  much,  therefore, 
may  be  predicted  if  one  sees  a  case  in  the  early  stages.  We 
know,  further,  from  post  mortem  evidence,  that  a  good  many 
ulcers  heal  without  ever  having  produced  noticeable  symp- 
toms. Beyond  this  it  is  difficult  to  make  any  accurate  state- 
ment, but  probably  something  more  than  half  the  cases 
gradually  recover  of  themselves,  and  the  somewhat  larger 
number  are  ameliorated  by  medical  or  surgical  treatment. 
There  is,  however,  a  marked  tendency  to  relapse  after  weeks 
or  months  of  freedom  from  all  symptoms,  and  one  must  also 
remember  that  in  a  not  inconsiderable  minority  of  the  cases 
the  ulcer  gives  no  sign  whatsoever  of  its  presence  until  per- 
foration of  the  stomach  wall  with  resulting  peritonitis  is 
present  or  imminent. 

What  proportion  of  cases  finally  becomes  transformed  into 
cancer  we  have  no  means  of  judging,  but  the  number  is 
probably  a  considerable  one. 

Beyond  this  the  prognosis  depends  very  largely  upon  the 
treatment  and  upon  the  intelligence  with  which  it  is  carried 
out. 

Treatment:  All  the  many  disputed  questions  relating  to 
the  treatment  of  peptic  ulcer  center  around  the  problem: 
When  should  surgical  interference  be  advised  ?  At  the  present 
time  the  great  majority  of  competent  observers  agree  that  in 
all  cases  one  should  operate: 

(a)    If  perforation  Is  present  or  imminent. 


INFECTIOUS   DISEASES.  3I 

(b)  If  pyloric  stenosis  and  the  resulting  gastrectasis  are 
such  as  to  cause  serious  suffering  and  malnutrition,  despite 
careful  diet. 

Physicians  are  not  In  agreement  regarding  the  advisabil- 
ity of  operation  (gastro-enterostomy)  for  severe  and  persistent 
haemorrhage.  There  is  also  a  considerable  difference  of  opin- 
ion regarding  the  question:  How  long  should  we  persist  with 
medical  treatment,  more  or  less  unsuccessful,  before  resorting 
to  operative  Interference  ?     My  own  opinion  is  as  follows : 

If  any  operation  Is  to  be  done  for  haemorrhage  It  should  be 
the  direct  transfusion  of  blood.  Then  after  the  anaemia  has 
been  overcome  and  the  haemorrhage  checked  one  may  con- 
sider upon  its  merits  the  question  of  operation  for  the  relief 
of  the  other  symptoms. 

We  should  not  consider  that  medical  treatment  has  been 
proved  a  failure  unless  It  has  been  carried  out  under  condi- 
tions involving  complete  rest  In  bed  and  an  efficient  control 
of  the  diet.  Very  few  cases  will  recover  under  ambulatory 
treatment,  and  even  under  the  best  and  most  thoroughly 
controlled  plan  of  management  one  must  expect  that  the 
patient  will  suffer  more  or  less  for  the  rest  of  his  life,  unless 
he  observes  certain  restrictions  as  to  the  quantity  and  qual- 
ity of  his  diet  and  unless  he  Is  able  to  avoid  unusual  strains 
of  mind  and  body. 

The  plan  of  treatment  which  has  been  most  successful  in 
my  hands  Is  a  modification  of  the  so-called  Lenhartz  treat- 
ment. I  believe  the  attempts  to  nourish  the  patient  by 
the  rectum  are  wholly  unsuccessful  In  the  vast  majority  of 
cases,  and  I  no  longer  attempt  rectal  feeding  as  such  In  this 
or  In  any  other  disease.  At  the  same  time  it  Is  valuable  to 
give  fluid  in  the  form  of  normal  saline  solution,  8  ounces, 
every  four  to  six  hours,  in  patients  whose  stomachs  cannot  be 
used  for  nutrition  owing  to  persistent  vomiting  or  to  recent 
and  profuse  haemorrhage.  As  a  rule  such  a  period  of  starva- 
tion with  fluid  supplied  by  rectum  need  be  neither  prolonged 
nor  painful.  We  can  almost  always  begin  to  feed  a  patient 
by  the  third  or  fourth  day.  The  period  of  seven  to  ten  days' 
total  starvation  (i.e.,  the  so-called  rectal  alimentation)  seems 
to  me  rarely,  if  ever,  of  value,  as  the  general  malnutrition 


32  CASE   HISTORIES    IN   MEDICINE. 

thus  produced  checks  the  healing  of  the  ulcer  more  than  the 
alimentary  repose  favors  it. 

Beginning  from  the  establishment  of  the  diagnosis  in  about 
nine-tenths  of  all  cases,  or  from  the  end  of  a  short  period 
of  starvation  in  the  comparatively  rare  cases  characterized 
by  obstinate  vomiting  or  haemorrhage,  the  diet  should  consist 
at  first  of  milk  and  powdered  crackers,  preferably  such  as 
leave  a  relatively  slight  residue  after  digestion.  From  3  to 
6  ounces  of  this  mixture,  which  may  be  sweetened  or  other- 
wise flavored,  should  be  given  every  three  or  four  hours, 
the  amount  depending  upon  the  patient's  appetite  and  upon 
the  degree  of  his  comfort.  Sometimes  the  amount  has  to 
be  reduced  or  the  carbohydrate  varied,  but  the  great  majority 
of  patients  will  take  this  diet  despite  its  monotony  for  ten 
days  or  two  weeks  without  serious  complaint.  After  this 
period  we  may  begin  to  give  other  carbohydrates  and  fats, 
avoiding  all  meat  and  meat  products  and  keeping  the  pro- 
portion of  fats  high.  The  essential  points  are  never  to  allow 
the  stomach  to  become  empty  for  any  considerable  period, 
to  keep  the  amount  of  cellulose  at  the  minimum,  and  to  avoid 
meat  and  salt.  The  first  of  these  objects  is  best  accomplished 
by  feeding  at  least  once  in  three  hours  and  by  giving  excess 
of  fat. 

During  the  early  weeks  of  treatment  the  patient  often  gets 
much  relief  from  sodic-bicarbonate  which  should  be  given  in 
unlimited  amount,  the  patient  taking  enough  to  check  his 
pain.  A  saucer  of  soda  (with  a  spoon  and  a  glass  of  water) 
should  be  left  at  the  bedside  and  its  use  explained  to  the 
patient.  Other  medication  has  not,  in  my  hands,  proved  of 
much  value,  though  many  recommend  the  use  of  teaspoonful 
doses  of  the  subcarbonate  of  bismuth  given  either  in  the 
morning  before  breakfast  or  at  regular  intervals  throughout 
the  day. 

It  is  essential  that  the  patient  should  remain  in  bed  during 
the  early  weeks  of  treatment  and  should  do  no  work  for 
several  months.  After  convalescence  the  patient  should  go 
without  meat  for  a  number  of  months  and  always  take  food 
at  least  as  often  as  once  in  three  hours  during  the  daytime. 
A  glass  of  milk,  reenforced  with  cream,  can  be  taken  by  most 


INFECTIOUS   DISEASES.  33 

patients  in  the  middle  of  the  morning  and  the  middle  of  the 
afternoon  with  benefit. 

Should  the  patient  relapse  and  suffer  severely  from  vomit- 
ing, pain,  or  haemorrhage,  the  same  regime  may  be  carried 
out  again.  Should  he  then  relapse  still  again,  gastro-enteros- 
tomy  may  be  advised. 


34  CASE   HISTORIES   IN   MEDICINE. 

Case  7.  I  was  called  April  30,  19 10,  to  an  unmarried 
woman  of  sixty-two,  in  complete  coma  which  has  lasted  for 
twenty  hours  and  been  accompanied  by  relaxed  sphincters. 
Seven  days  ago  the  patient  began  to  be  chilly  and  thirsty. 
Three  days  ago  a  swelling  was  noticed  in  the  leg  and  she 
complained  of  sore  throat.  Fever  ranging  from  103°  to  104.5° 
had  been  present  for  four  days  at  least.  The  patient  has  been 
previously  well  though  she  has  been  known  to  have  albu- 
minuria for  some  years.  She  has  had  no  convulsion,  no  vomit- 
ing and  no  headache.     No  paralysis  has  been  noticed. 

On  examination  the  patient  could  not  be  roused  from  coma. 
There  was  no  stiffness  of  the  neck  and  no  strabismus,  but  the 
left  eye  showed  marked  purulent  conjunctivitis.  The  heart's 
apex  was  in  the  fifth  space,  three-quarters  of  an  inch  outside 
the  nipple.  The  sounds  were  regular,  rapid,  clear.  The 
lungs  and  abdomen  were  negative.  The  left  leg  below  the 
knee  was  swollen  and  red,  especially  about  the  ankle  and  the 
dorsum  of  the  foot,  which  was  very  tense,  shiny,  and  intensely 
red  though  without  any  line  of  demarcation.  Though  obvi- 
ously in  deep  coma  and  insensitive  to  touch  in  other  parts 
of  the  body,  the  patient  winced  and  stirred  when  the  foot  was 
touched.  The  blood  showed  24,200  leucocytes,  with  96%  of 
polynuclears  and  no  eosinophiles.  It  was  not  otherwise  re- 
markable. Lumbar  puncture  liberated  a  clear  fluid  without 
tension.  There  w^as  no  excess  of  cells  and  no  organisms 
were  found. 

1.  Common  causes  of  febrile  coma?    All  forms  of  meningitis; 

the  terminal  stages  of  various  infectious  diseases;  any 
injury  or  disease  of  the  brain,  such  as  apoplexy  or  cere- 
bral tumor  may  likewise  be  accompanied  by  coma  and 
fever.     The  same  is  true  of  uraemia. 

2.  What  is  the  significance  of  the  order  in  which  the  symp- 

toms occurred  in  this  case?  The  fact  that  the  fever 
preceded  the  coma  by  at  least  four,  and  probably  six 
days,  makes  it  almost  certain  that  we  are  dealing  with 
the  cerebral  manifestations  of  general  infection  rather 
than  with  a  febrile  reaction  supervening  on  some  local 
lesion  like  tumor  or  haemorrhage. 

Diagnosis:  The  entire  absence  of  headache  and  the  condi- 
tion of  the  cerebral  spinal  fluid  sufficed  to  exclude,  meningitis. 


INFECTIOUS   DISEASES.  35 

It  remains  to  decide  what  general  infectious  disease  is  most 
probably  the  cause  of  the  symptoms.  In  view  of  the  patient's 
age,  the  history  of  long-standing  albuminuria,  and  the  ful- 
minating course  of  the  symptoms,  which  has  brought  the 
patient  to  death's  door  within  a  week,  it  is  suggested  that 
we  may  be  dealing  with  one  of  those  unlocalized,  terminal 
infections  which  so  often  complicate  a  chronic  nephritis.  But 
the  condition  of  the  left  ankle  is  strongly  suggestive  of  a  local 
streptococcus  infection  of  the  type  occupying  the  border  line 
between  erysipelas  and  a  more  diffuse  phlegmonous  or  infil- 
trating cellulitis. 

Although  no  blood  culture  was  made,  it  seems  reasonable 
to  conclude  that  the  case  is  one  of  general  terminal  strepto- 
coccus septicaemia  with  the  focus  of  infection  in  and  near  the 
left  ankle. 

Prognosis:  The  outlook  in  cases  of  generalized  septicaemia 
depends  upon  the  following  factors: 

1.  The  organism  responsible. 

2.  The  general  condition  of  the  patient  previous  to  infection. 

3.  The  constitutional  manifestations  of  infection. 

The  streptococcus  is  the  worst,  as  well  as  the  commonest 
of  the  infecting  organisms.  Pneumococci  are  less  serious. 
Patients  whose  resistance  is  already  weakened  by  arterio- 
sclerosis, chronic  nephritis,  hepatic  cirrhosis,  or  other  debili- 
tating diseases  offer  little  opposition  to  the  infection. 

Other  things  being  equal,  the  higher  the  temperature,  pulse, 
and  leucocyte  count,  the  greater  the  muscular  prostration, 
the  more  disturbed  the  nervous  system  (stupor,  delirium), 
the  worse  the  outlook. 

Treatment:  If  any  focus  of  infection  can  be  discovered,  it 
should  receive  prompt  surgical  attention.  Otherwise,  the 
treatment  resolves  itself  into  hygiene  and  nursing,  i.e.,  rest  in 
bed,  nutritious  but  easily  digested  diet,  laxatives  if  necessary 
to  promote  proper  bowel  action,  and  hypnotics  if  necessary 
for  sleep.     Heart  stimulants  and  vaccines  do  no  good. 


36  CASE  HISTORIES   IN   MEDICINE. 

'  Case  8.  A  business  man  of  sixty-two  was  seen  at  his  sum- 
mer camp  in  the  Adirondacks  September  19,  1910.  He  had 
been  seriously  ill  there  for  five  weeks.  I  was  consulted  re- 
garding the  possibility  of  moving  him  to  his  home  in  Buffalo. 
The  attending  physician  gave  the  following  account  of  the 
case:  Up  to  the  age  of  fifty- five  he  was  always  well.  Then 
he  began  to  have  curious  heart  attacks,  resembling  paroxysmal 
tachycardia,  the  attacks  occurring  every  week  or  two,  and 
lasting  from  an  hour  to  ten  days.  Both  the  onset  and  the 
termination  of  these  attacks  were  absolutely  sudden  and 
treatment  made  very  little  difference. 

Three  years  ago  he  began  to  have  a  great  deal  of  prostatic 
trouble;  an  operation  was  proposed,  but  declined  because  of 
the  condition  of  the  heart.  Two  years  ago  he  was  in  bed  for 
thirteen  weeks  with  acute  prostatic  inflammation  accom- 
panied by  epididymitis,  pyuria,  haematuria,  chills,  fever,  and 
leucocytosis.  During  this  time  he  had  one  thirteen-day 
period  of  rapid  and  irregular  heart  action.  Since  that  time 
the  heart  trouble  has  been  practically  as  before  this  attack. 
There  have  been  several  relapses  of  the  local  prostatic  trouble, 
apparently  brought  on  by  sitting  up  for  any  length  of  time, 
and  by  joggling,  especially  on  journeys.  During  the  past 
summer  he  has  had  short  cardiac  attacks  as  usual  about  every 
six  days.  August  15  he  had  tonsilitis  with  folicular  inflam- 
mation and  fever  lasting  two  or  three  days.  August  28  the 
sore  throat  and  fever  returned,  and  the  fever  has  persisted 
ever  since,  varying  from  99°  to  103°  with  frequent  chills.  The 
leucocytes  varied  between  13,000  and  19,000,  the  pulse  be- 
tween 48  and  60.  An  astonishing  feature  of  the  attack  has 
been  the  entire  freedom  from  cardiac  symptoms,  the  longest 
period  of  respite  which  he  can  remember  during  seven  years. 
The  urine  has  varied  from  1200  to  1500  c.c.  It  has  always 
contained  pus  and  colon  bacilli.  This  colon  bacillus  infection 
has  been  known  to  be  present  for  many  months  and  vaccines 
have  been  given  for  it  off  and  on  without  any  notable  effect. 
The  amount  of  pus  varies  from  a  trace  to  2%  by  volume.  All 
the  pus  is  passed  with  the  first  ounce  of  urine.  Small  blood 
clots  occasionally  accompany  it.  The  specific  gravity  is  from 
1012  to  1018,  and  occasionally  a  few  hyaline  casts  are  found. 


INFECTIOUS   DISEASES.  37 

Larger  or  smaller  traces  of  albumin  are  always  present.  The 
patient  has  been  in  bed  continuously  since  August  29.  His 
appetite  is  usually  poor  and  he  is  losing  weight.  During  the 
attacks  of  high  fever,  which  occur  at  frequent  intervals,  he 
vomits  and  is  often  delirious  or  stuporous  for  hours. 

On  examination  the  patient  was  clear  in  his  mind,  and 
showed  a  fair  amount  of  muscular  strength  despite  moderate 
emaciation.  His  heart  was  normal,  save  for  a  slight  accen- 
tuation of  the  aortic  second  sound.  Blood  pressure  165 
mm.  Hg.  Except  for  the  condition  of  the  urine  physical 
examination  was  otherwise  negative. 

The  camp  in  which  I  saw  the  patient  was  on  a  lake  high  up 
in  the  mountains.  To  move  him  to  his  home  would  involve 
his  being  carried  down  some  2000  feet  in  a  litter  over  a  rough 
path,  then  an  hour's  automobile  ride  and  a  night's  journey  in 
the  train. 

1.  Are  the  patient's  fever  and  other  symptoms  due  to  the  local 

infection  alone,  i.e.,  to  a  cystitis  depending  upon  pros- 
tatic obstruction  with  or  without  an  extension  of  the 
inflammation  up  the  ureters  to  the  renal  pelvis? 
Malignant  endocarditis  or  some  other  obscure  form 
of  septicaemia  had  been  seriously  considered  by  the 
attending  physician,  but  the  physical  examination 
seemed  to  me  to  offer  no  support  for  any  such  serious 
hypothesis.  There  were  no  evidences  of  septic  embol- 
ism, no  constant  cardiac  murmurs,  and  no  more  fever 
or  leucocytosis  than  could  be  accounted  for  by  the 
local  bladder  trouble.  Were  the  heart  seriously  weak 
there  should  be  some  signs  of  stasis  in  the  lungs  or 
elsewhere.  The  presence  of  repeated  chills  does  not 
militate  at  all  against  the  diagnosis  of  cystitis  and 
pyelitis. 

2.  What  is  the  nature  of  the  cardiac  attacks,  and  why  should 

they  so  suddenly  have  ceased  ?  It  seems  probable 
that  these  attacks  are  due  to  some  form  of  defective 
conductivity  of  the  impulse  of  cardiac  contraction.  I 
can  assign  no  reason  for  their  disappearance,  although 
there  are  many  parallel  instances  of  one  disease  ceasing 
to  manifest  itself  when  another  supervenes. 

3.  Is  it  desirable,  and  if  so,  is  it  safe  to  move  this  patient  to 

his  home?  In  my  opinion  it  is  both  safe  and  desirable. 
The  treatment  of  the  original  cause  for  his  symptoms  is 


38  CASE  HISTORIES   IN  MEDICINE. 

a  matter  demanding  expert  surgical  care  such  as  cannot 
be  secured  in  camp.  The  disease  shows  no  signs  of 
subsiding  spontaneously,  and  winter  with  increased 
difficulties  in  traveling  is  approaching.  Very  few 
patients  with  any  form  of  disease  are  seriously  or  per- 
manently harmed  by  a  move  of  this  kind,  unless  there 
is  very  obvious  cardiac  weakness,  which  is  not  here 
present. 

In  accordance  with  this  belief  the  patient  was  moved  to  his 
home  four  days  later  although  he  had  had  a  bad  chill  on  the 
day  preceding  his  start.  Nevertheless  he  made  the  journey 
with  a  fair  degree  of  comfort  and  seemed  to  be  no  worse  for  it. 

A  year  later,  after  prostatectomy,  he  was  decidedly  better. 


INFECTIOUS  DISEASES.  39 

Case  9.  A  married  woman,  aged  twenty-seven,  is  seen 
June  7.  Both  parents  died  of  consumption.  She  has  always 
been  well  except  for  an  attack  of  rheumatic  fever  three  years 
ago.  Has  had  four  healthy  children,  the  youngest  six  months 
old.  Her  oldest  child  was  taken  with  convulsions  on  the 
night  of  June  2,  and  died  twelve  hours  later.  After  his 
death  she  seemed  dazed  and  became  delirious,  but  had  inter- 
vals of  apparent  consciousness  up  to  6  p.m.,  when  she  com- 
plained of  pain  in  the  back  of  her  neck  and  began  to  vomit. 
Vomiting  was  frequent  and  persistent  until  the  following 
evening.  She  has  remained  unconscious  since  the  evening 
of  the  third.  Yesterday  morning  her  hands  and  feet  ap- 
peared swollen  and  inflamed.  Her  temperature  has  varied 
between  101°  and  102.5°  and  has  been  irregular.  Her  pulse 
is  120,  respirations  30.  She  is  delirious,  and  does  not  appear 
to  realize  her  surroundings.  Both  knee  and  ankles,  the  back 
of  the  left  hand  and  the  metacarpophalangeal  joint  of  the 
right  index  finger  are  red,  swollen,  and  tender.  There  is 
redness  over  both  patellae.  The  muscles  of  the  calves  and 
thighs  are  tender.  The  neck  is  somewhat  stiff,  the  pupils 
dilated,  and  there  is  divergent  strabismus.  The  knee-jerks 
are  not  obtained.  Except  for  a  few  moist  rales  at  the  bases 
of  the  lungs,  physical  examination  is  otherwise  negative.  The 
white  cells  number  29,400.  Urine:  specific  gravity  1030,  acid, 
albumin  very  slight  trace,  sugar  a  trace.  Sediment  contains 
occasional  hyalin  and  fine  granular  casts  and  a  rare  abnor- 
mal blood  globule.     The  24  hr.  amount  is  500  c.c. 

1.  What  changes  might  be  revealed  by  ophthalmoscopic  ex- 

amination ?    Optic  neuritis,  choroid  tubercles  (very  rare). 

2.  Discuss  the  urinary  anomalies  in  this  case.     Passive  con- 

gestion and  the  acute  degeneration  resulting  from  any 
infectious  fever  are  the  commonest  causes  of  such  urine. 
The  glycosuria  is  probably  due  to  cerebral  irritation. 

3.  What  are  the  most  important  types  and  causes  of  arthri- 

tis ?     (See  below,  Case  94.) 

4.  Name  three  causes  of   strabismus.     Congenital,  tubercu- 

lous meningitis,  syphilis. 

5.  What  tests  would  simplify  the  diagnosis  ?     Spinal  punc- 

ture, ophthalmoscopy. 

6.  How  is  the  vomiting  to  be  explained  in  this  case  ?     The 

onset  of  an  infectious  disease. 


40  CASE   HISTORIES   IN    MEDICINE. 

Diagnosis:  At  autopsy  tuberculous  meningitis  and  gen- 
eral miliary  tuberculosis  were  found.  The  family  history, 
the  sudden  onset  of  fever,  coma,  delirium,  retraction  of  the 
neck  and  strabismus  make  this  diagnosis  obvious.  The 
pains  in  the  peripheral  joints  and  muscles  are  to  be  explained 
as  a  part  of  the  general  infectious  process,  though  in  all 
probability  no  gross  tuberculous  lesions  were  present  there. 
The  type  of  meningitis  would  be  revealed  by  spinal  puncture. 

Prognosis:  Since  the  more  frequent  use  of  lumbar  punc- 
ture with  the  staining  and  bacteriological  examination  of 
the  sediment  from  the  spinal  fluid,  it  has  become  evident  that 
tuberculous  meningitis  is  not  an  absolutely  fatal  disease. 
Perhaps  one  case  in  four  or  five  hundred  recovers.  So  far 
as  I  know  there  Is  nothing  to  distinguish  these  rare  favorable 
cases  from  the  great  mass  of  unfavorable  ones,  but  in  every 
case  we  can  truthfully  say  to  the  family  that  there  Is  hope 
and  that  recovery  Is  possible.  Even  In  the  most  favorable 
cases  convalescence  requires  many  months. 

Treatment:  Our  chief  objects  should  be  to  maintain  nutri- 
tion, to  prevent  bed-sores,  and  to  relieve  symptoms  of  cerebral 
compression  (Internal  hydrocephalus)  by  frequent  puncture" 
of  the  spinal  canal.  In  maintaining  nutrition  the  dominant 
factor  is  the  skill  and  tact  of  the  nurse  who,  by  coaxing  and 
persuasion  as  well  as  by  the  attractiveness  and  flavor  of  the 
food  which  she  serves,  may  succeed  In  getting  the  patient  to 
take  an  amount  of  food  which  would  be  quite  impossible 
without  this  personal  skill. 

The  prevention  of  bed-sores  Is  accomplished  by  keeping 
the  skin  and  the  bed  as  dry  and  clean  as  possible,  by  turning 
the  patient  frequently  from  one  side  to  the  other  so  that  no 
one  prominent  part  is  long  impinged  upon,  and  by  protecting 
the  sacrum,  the  great  trochanters  and  the  heels  with  rings 
of  rubber  or  cotton. 

Lumbar  puncture  should  be  performed  whenever  evidences 
of  cerebral  compression  are  Increasing.  Such  evidences  are: 
a  deepening  stupor,  strabismus,  vomiting  and  choked  disk. 


INFECTIOUS  DISEASES.  4I 

Case  10.  A  teamster  of  forty-five  entered  the  hospital 
February  i,  191 1.  For  three  years  he  has  been  complaining 
of  dyspnoea  and  swelling  of  the  feet,  increased  by  any  exer- 
tion, passing  off  when  he  was  able  to  be  completely  at  rest. 
So  far  as  he  knows  he  has  had  no  previous  illness,  no  chorea, 
rheumatic  fever,  diphtheria,  or  scarlet  fever.  He  denies 
venereal  disease.  He  takes  two  beers  and  two  or  three 
whiske^'^s  a  day. 

In  May,  1909,  his  first  attack  of  very  severe  dyspnoea  was 
accompanied  by  a  multiple  arthritis  with  many  purpuric 
spots.  For  several  days  during  this  attack  he  had  Cheyne- 
Stokes  breathing.  After  this  attack  he  felt  much  better  and 
did  a  little  light  work  off  and  on  until  six  months  ago.  Since 
then  oedema  has  been  almost  constant  and  has  extended  up 
the  legs  to  the  abdomen  and  also  to  the  hands.  The  last 
three  weeks  he  has  been  much  troubled  with  cough,  but  has 
expectorated  only  a  watery  fluid. 

On  physical  examination  there  is  cyanosis  and  orthopnoea. 
The  heart's  impulse  extends  7  cm.  outside  the  nipple  line 
in  the  sixth  space.  There  is  a  loud  systolic  murmur  best 
heard  at  the  apex  but  very  widely  transmitted.  A  diastolic 
murmur  is  also  heard  along  the  left  border  of  the  sternum, 
and  another  systolic  of  harsher  quality  in  the  second  right 
interspace.  There  is  systolic  venous  pulsation  in  the  neck, 
and  the  liver  is  markedly  enlarged.  Free  fluid  is  easily 
demonstrated  in  the  abdomen.  The  pulse  is  distinctly  of  the 
Corrigan  type.  The  lungs  and  extremities  are  markedly 
oedematous.  On  the  7th  of  February  a  systolic  thrill  was 
easily  felt  over  the  manubrium  and  it  was  noticed  that  the 
whole  right  front  retracted  slightly  with  each  systole,  as  did 
the  tenth  space  below  the  angle  of  the  left  scapula. 

His  systolic  blood  pressure  was  150.  Urine  high  colored, 
20  ounces  in  24  hours,  with  a  specific  gravity  of  1022,  a  large 
trace  of  albumin,  a  few  hyalin  and  granular  casts.  The  blood 
examination  showed  nothing  abnormal.  During  a  week's  ob- 
servation, the  temperature  was  persistently  subnormal,  and 
the  pulse  rate  normal. 

Diagnosis:  It  seems  pretty  clear  that  we  are  dealing  with 
aortic  regurgitation  and  mitral  regurgitation.     The  cause  and 


42  CASE   HISTORIES   IN   MEDICINE. 

nature  of  the  leaks  are  the  only  points  that  call  for  discussion. 
Is  the  lesion  rheumatic,  syphilitic,  or  arteriosclerotic  ?  We 
have  no  positive  evidence  of  arteriosclerosis,  and  although 
such  disease  may  be  present  we  should  not  so  assume  unless 
no  other  diagnosis  is  possible. 

It  must  be  admitted  that  we  may  have  the  rheumatic  type 
of  endocarditis  without  any  evidence  of  joint  troubles.  In 
this  patient  there  were  joint  troubles  at  the  beginning  of  his 
illness,  but  it  may  be  doubted  whether  these  were  of  the 
ordinary  rheumatic  type,  since  acute  rheumatism  rarely  begins 
at  43.  The  possibility  of  a  syphilitic  aortitis  must  certainly 
be  considered.  Further  light  can  scarcely  be  obtained  unless 
a  Wasserman  test  is  made.  An  X-ray  of  the  bones  of  the 
lower  leg  may  also  throw  some  light  upon  the  disease,  since 
syphilitic  periostitis  is  not  infrequently  demonstrated  in  such 
a  case,  even  though  the  patient  may  have  had  no  knowledge 
Df  any  such  infection. 

The  Wasserman  reaction  proved  positive,  and  an  X-ray  of 
the  shin  showed  lesions  typical  of  periostitis  (see  Plate  I). 

Prognosis:  In  the  great  majority  of  cases  this  lesion  re- 
mains latent  until  within  two  or  three  years  from  the  time 
of  death.  After  symptoms  declare  themselves,  therefore,  we 
cannot  often  promise  more  than  this  span  of  life.  Anti- 
syphilitic  treatment  has,  in  my  hands,  given  no  brilliant 
results.  Nevertheless  it  should  always  be  undertaken  and 
conscientiously  carried  out. 

Treatment:  Daily  inunctions  of  mercury,  10  grains  of 
iodide  of  potash  after  each  meal,  complete  rest  in  bed,  an 
ounce  of  magnesium  sulphate  in  concentrated  solution  each 
morning  before  breakfast,  diuretin  15  to  30  grains  every 
four  hours,  and  possibly  digitalis,  are  of  benefit.  In  spite  of 
these  remedies  the  patient  whose  case  is  here  narrated  died 
on  the  23d  of  February.  His  heart  weighed  820  grams.  A 
syphilitic  aortitis  was  found  with  aortic  regurgitation  and  a 
slight  generalized  dilatation  of  the  aorta  without  any  obvious 
rupture  of  the  coats.  There  was  no  stenosis  of  the  aortic 
valve;  except  for  a  general  passive  congestion  the  organs 
showed  nothing  else  of  interest. 


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INFECTIOUS   DISEASES. 


43 


Case  II.  A  well-developed  and  fairly  well-nourished  man, 
eighteen  years  old,  is  seen  for  the  first  time  February  26. 
His  father  died  of  consumption,  his  mother  of  rheumatism 
and  heart  disease.  He  has  never  drunk  steadily,  though 
occasionally  to  excess.  He  chews  five  cents'  worth  of  tobacco 
and  smokes  twenty  cigarettes  daily.  For  eighteen  months, 
ending  seven  months  ago,  he  had  almost  daily  coitus.  For 
the  last  six  months  he  has  had  gonorrhoea.  When  a  child  he 
had  diphtheria,  at  fourteen  typhoid,  for  the  past  seven  months 
pain  in  the  epigastrium,  on  rising,  and  latterly  some  pains 
about  the  head.  Ten  days  ago,  when  he  tried  to  get  up,  he 
had  vertigo,  chilliness,  sweating,  and  a  feeling  of  unsteadiness. 
He  has  been  in  bed  most  of  the  time  since. 

The  present  symptoms  are:  weakness,  backache,  epigastric 
pain  (without  nausea  or  vomiting) ,  cough  with  white  expectora- 
tion, thirst,  headache,  and  constipation.  His  chief  complaint 
is  weakness;  next  to  that  headache  and  dizziness.  There  is 
some  dyspnoea,  but  the  cough  is  not  troublesome.  There  has 
been  no  nosebleed. 

The  patient  is  pale.  His  pupils  are  equal  and  react  to 
light.  The  tongue  is  protruded  promptly  and  in  a  straight 
line,  is  not  particularly  tremulous  and  bears  a  slight  white 
coat.  Both  sides  of  the  chest  move  equally;  there  are  no 
areas  of  marked  dulness,  of  increased  vocal  resonance,  or  of 
bronchial  breathing.  A  few  coarse,  crackling  rales  are  heard 
persistently  at  the  right  apex.  The  heart's  apex  is  in  the 
fourth  space  in  the  nipple  line.  There  is  no  murmur  nor  en- 
largement. The  pectoral  muscle  contracts  when  percussed. 
The  skin  flushes  easily.  The  abdomen  is  enlarged,  tympanitic 
not  tender.  There  is  gurgling  in  the  right  iliac  fossa.  The 
spleen  cannot  be  felt;  its  area  is  tympanitic.  The  hepatic 
area  is  normal.  There  are  no  rose  spots.  The  knee-jerks  are 
lively.  A  few  glands  are  felt  in  the  left  side  of  the  neck,  and 
on  the  right  side  is  a  scar.  The  white  cells  number  3600. 
Temperature  101°,  pulse  80,  respirations  25.  The  urine  has 
a  slight  trace  of  albumin,  with  a  sediment  containing  pus  and 
squamous  epithelium.  No  diazo  reaction  is  present.  No 
tubercle  bacilli  are  found  in  the  sputum. 

During  the  next  five  days  the  temperature  is  irregular,  vary- 


44  CASE   HISTORIES   IN   MEDICINE. 

ing  between  99°  and  103°.  The  respirations  rise  slightly,  to 
30.  On  March  i  a  faint  diazo  reaction  is  obtained.  The 
headache  ceases  after  February  29.  Constipation  persists. 
On  March  2  the  physical  examination  is  the  same  as  on  Feb- 
ruary 26.  On  March  3  there  is  involuntary  micturition, 
Cheyne-Stokes  respiration,  and  external  strabismus.  Noth- 
ing peculiar  is  noticed  about  the  neck. 

1.  What  are  the  most  significant  facts  in  this  case?     The 

family  history  of  tuberculosis,  the  debilitating  habits, 
the  existing  gonorrhoea,  the  headache  and  vertigo,  the 
persistent  rales  at  the  right  apex,  the  fever,  the  leuco- 
penia,  the  headache,  Cheyne-Stokes  breathing,  and 
strabismus. 

2.  What  is  the  importance  of  the  pulmonary  signs  ?     In  spite 

of  the  absence  of  the  tubercle  bacilli  in  the  sputum, 
such  signs  are  distinctly  suggestive  of  tuberculosis. 
They  may,  however,  result  from  bronchopneumonia 
due  to  influenza  or  to  unknown  infections. 

3.  Why  is  the  cardiac  impulse  displaced  upward?     Because 

of  the  abdominal  distention. 

4.  What  do  you  infer  if  a  pectoral  muscle  contracts  when 

percussed  ?  Increased  muscular  irritability,  such  as 
is  present  in  many  cases  of  debility,  however  produced. 

5.  Does  the  course  of  the  temperature  curve  suggest  any  par- 

ticular disease?  Such  a  curve  is  most  often  seen  in 
pyogenic  infections. 

6.  What  is  the  value  of  the  diazo  reaction  in  this  case  ?     The 

presence  of  a  diazo  reaction  is  never  of  considerable 
diagnostic  value,  though  its  absence  in  a  febrile  case 
argues  against  typhoid.  In  any  disease  it  is  a  bad 
prognostic  sign. 

7.  What  is  the  value  of  the  sputum  examination  in  this  case  ? 

A  single  negative  sputum  examination  must  be  re- 
peatedly confirmed  before  it  becomes  evidence  against 
pulmonary  tuberculosis. 

8.  What  further  examinations  should  be  made  in  this  case? 

None  is  essential,  but  a  Widal  test  and  a  lumbar  punc- 
ture would  help  to  decide  the  question  between  typhoid 
and  meningitis,  and  if  the  latter  exists,  to  determine  the 
organism  to  which  it  is  due. 

9.  How  do  you  explain  the  condition  of  the  neck  ?     Only  by 

saying  that  any  single  symptom  of  any  disease  may 
be  absent  in  a  particular  case. 


INFECTIOUS   DISEASES.  45 

Diagnosis :  The  data  collected  in  the  answer  to  question  i 
point  strongly  toward  acute  general  tuberculosis  with  pre- 
dominant meningeal  symptoms.  Typhoid  fever  is  the  most 
important  alternative,  but  seems  unlikely,  In  view  of  the 
marked  cerebral  symptoms.  A  Widal  reaction  would  help 
to  settle  this  question,  also  a  lumbar  puncture.  The  leuco- 
penia  is  consistent  with  tuberculous  meningitis,  but  not  with 
other  types.  The  family  history  of  tuberculosis,  the  cervical 
adenitis,  the  scar,  and  the  signs  at  the  right  pulmonary  apex, 
also  support  the  diagnosis  of  general  tuberculous  infection. 
The  temperature  Is  consistent,  likewise  the  diazo  reaction. 
The  condition  of  the  abdomen  is  one  often  seen  in  a  variety 
of  Infectious  diseases. 

In  the  further  course  of  the  case,  the  mental  dulness 
deepened  to  stupor,  the  pulse  gradually  fell  to  70,  swallowing 
became  difficult,  ankle-clonus  appeared,  and  the  arms  were 
at  times  rigid  and  contracted.  In  view  of  all  these  facts, 
the  diagnosis  of  general  tuberculosis  with  meningitis  was 
made  with  confidence  and  was  confirmed  at  autopsy. 

Prognosis  and  Treatment  (see  above.  Case  9.) 


46  CASE   HISTORIES   IN   MEDICINE. 

Case  12.  A  man  of  twenty-three  returned  two  months 
ago  from  Mexico  where  he  had  spent  six  weeks.  He  arrived 
in  good  health.  The  following  day  he  suffered  from  head- 
ache; the  third  day  he  went  to  bed  and  has  been  there  since, 
with  a  continuous  fever  varying  most  of  the  time  from  two 
degrees  to  three  degrees  daily;  sometimes  103°,  more  often 
102°  in  the  evening.  He  complained  of  pain  in  the  lower  left 
chest,  transient  but  soon  reappearing  in  the  lower  right  chest 
and  over  the  region  of  the  liver  anteriorly.  This  latter  region 
was  at  times  tender.  Pain  and  tenderness  have  now  disap- 
peared.    His  bowels  have  been  costive;  at  no  time  diarrhoea. 

After  a  month's  illness  there  was  a  slight  leucocytosis  — 
10,000  to  12,000;  absence  of  plasmodia  and  of  the  Widal  re- 
action. Three  weeks  ago  he  began  to  cough  violently,  and 
since  then  has  raised  a  curious  sputum,  blood-stained,  thick, 
but  non-purulent.  Coincident  with  this  the  temperature 
rose  four  or  five  degrees;  after  two  or  three  days  it  fell  and 
then  followed  its  usual  course.  He  now  has  considerable 
annoying  secretion  of  saliva.  He  still  continues  to  expecto- 
rate. The  liver  is  somewhat  large.  The  spleen  is  also  slightly 
enlarged. 

Examination  showed  a  nervous  young  man,  somewhat 
emaciated,  complaining  of  weakness  and  malaise,  and  of 
nothing  else  except  the  straining  and  coughing. ,  The  lungs 
were  normal,  save  at  the  right  base  posteriorly  where  the 
breathing  was  diminished.  Anteriorly  the  upper  border  of 
the  liver  reached  the  fourth  interspace;  the  lower  edge  was 
easily  felt  below  the  ribs.  The  spleen  was  just  palpable  and 
reached  the  seventh  rib  above;  the  abdomen  was  otherwise 
negative.     The  first  heart  sound  was  feeble. 

Diagnosis:  Continued  fever,  slight  leucocytosis,  pain  in 
the  region  of  the  liver,  and  the  expectoration  of  a  blood- 
stained but  non-purulent  sputum  occurring  in  a  man  recently 
returned  from  a  tropical  climate  makes  a  very  suggestive 
clinical  picture.  The  localization  of  the  pain  suggests  some- 
thing in  the  liver;  fever  suggests  that  this  something  is  of  an 
infectious  origin,  possibly  an  abscess.  This  is  all  the  more 
probable  since  the  patient  has  recently  returned  from  Mexico. 
Now,  since  it  is  well  known  that  amoebic  abscess  of  the  liver 


INFECTIOUS    DISEASES.  47 

may  perforate  into  the  lung  and  produce  an  expectoration 
like  that  here  described,  the  pulmonary  signs  go  to  support 
the  diagnosis  of  hepatic  abscess,  especially  since  jaundice 
is  absent  and  the  commoner  causes  of  hepatic  enlargement 
can  apparently  be  excluded. 

Prognosis :  Arhoebic  abscess  of  the  liver  goes  on  to  recovery 
in  a  considerable  portion  of  cases,  provided  that  free  drain- 
age can  be  established  either  by  surgical  interference  or 
through  the  lung.  The  latter  passageway  is  seldom  sufficient 
and  as  a  rule  becomes  obstructed,  forcing  the  patient  to 
seek  relief  by  operative  measures.  In  individual  cases  the 
prognosis  depends  upon  the  duration  of  the  symptoms,  the 
severity  of  constitutional  manifestations,  such  as  fever,  high 
pulse,  chills,  sweats,  emaciation,  digestive  disturbances,  and 
insomnia.  If  the  patient  is  in  good  condition  at  the  time  of 
operation  we  have  good  reason  to  be  hopeful  of  the  ultimate 
outcome,  since  amoebic  abscess  is  often  single  and  capable 
of  being  efficiently  drained. 

Treatment:  As  soon  as  diagnosis  is  established,  or  reason- 
ably probable,  surgical  interference  should  be  urged.  We  have 
no  other  way  of  helping  the  patient. 


48  CASE   HISTORIES   IN   MEDICINE. 

Case  13.  A  girl  of  nineteen  is  seen  May  26.  Her  mater- 
nal grandfather  died  of  phthisis.  Family  history  otherwise 
good.  She  has  always  been  rather  pale  and  delicate,  but 
has  had  no  definite  or  serious  illness.  At  the  end  of  Febru- 
ary she  consulted  her  physician  for  slight  swelling  of  the 
glands  on  the  left  side  of  the  neck.  The  temperature  was 
slightly  elevated  when  taken  after  this,  and  during  the  next 
two  weeks  the  glands  increased  considerably  in  size  and  she 
had  some  cough,  apparently  due  to  bronchitis.  Toward  the 
end  of  March  she  began  to  improve  and  the  glandular  swell- 
ing to  subside.  The  appetite  increased  and  she  got  out. 
Two  weeks  ago  she  was  less  well;  fever  returned  to  a  moder- 
ate degree,  as  did  cough,  and  slight  crepitus  was  heard  under 
both  clavicles.  One  week  ago,  the  day  being  mild,  she  sat 
on  the  doorstep  and  experienced  a  sudden  pain  at  the  root 
of  the  nose,  just  between  the  eyes.  This  pain  extended  over 
the  forehead,  increased  in  intensity,  and  was  relieved  more 
by  cold  than  by  hot  applications.  Four  days  ago  without 
obvious  cause  she  vomited  once.  The  next  day  she  vomited 
again  and  the  headache  became  intense.  For  the  past 
forty-eight  hours  she  has  retained  nothing  on  her  stomach. 
To-day,  there  was  slight  hiccough  after  vomiting  and  the 
menses  appeared,  the  first  time  for  three  months.  Morphia 
by  the  mouth  gave  her  no  relief.  In  the  last  twelve  hours 
she  has  had  three  suppositories  containing  a  quarter  of  a 
grain  of  morphia  each,  with  only  partial  relief  to  her  head- 
ache. Before  the  morphia  was  begun  the  pupils  were  large, 
equal,  and  reacted  equally  to  light.  Her  aunt  states  that  the 
pupils  have  always  been  large.  They  are  now  moderately  con- 
tracted, equal,  and  respond  normally.  Photophobia.  The 
pulse  has  ranged  90  to  100.  Temperature  99°  this  morning, 
100°  last  night. 

The  pulse  is  now  60  to  100,  changing  its  rate  quickly  and 
frequently.  Respiration  easy.  The  mind  seems  clear,  but 
she  is  disinclined  to  talk  or  make  any  effort. 

The  glands  in  the  right  side  of  the  neck  are  slightly  en- 
larged. The  heart  is  negative.  No  rales  are  detected  over 
the  fronts.  The  backs  are  not  examined  as  it  does  not  seem 
wise  to  disturb  her  to  that  extent.     Abdominal  examination 


INFECTIOUS    DISEASES.  49 

gives  negative  results.  The  reflexes,  superficial  and  deep,  are 
not  obtained.  Urine  negative.  Neither  the  sputum  nor  the 
blood  have  been  examined.     There  is  no  paralysis. 

1.  What  can  be  inferred  from  the  effect  of  the  morphia  here  ? 

That  the  headache  was  of  an  intensity  rarely  seen  except 
in  organic  brain  disease,  in  uraemia  and  in  exceptional 
instances  of  malarial  infection. 

2.  Significance  of  the  way  the  headache  came  on  ?     The  cir- 

cumstances probably  had  nothing  to  do  with  it.  The 
suddenness  of  onset  is  not  characteristic  of  any  single 
disease. 

3.  In  what  diseases  do  the  pupils  give  the  most  important  in- 

formation ?  Tabes  dorsalis,  general  paralysis,  old  iritis, 
morphia  poisoning,  aneurism  of  the  aorta. 

4.  What  cervical  tumors  are  commonest?     Adenitis  (tuber- 

culous or  septic),  Hodgkins  disease,  leucaemia,  cervical 
rib,  branchial  cysts,  cancer,  and  sarcoma. 

5.  What  help  could  be  gained  by  examination  of  the  blood 

and  sputa  in  this  case?  Normal  blood  would  speak 
against  meningitis,  though  in  some  tuberculous  cases 
leucocytosis  is  absent.  The  presence  or  absence  ^f 
malarial  parasites  is  important,  as  malaria  may  cause 
marked  cerebral  symptoms.  If  the  Widal  reacticn 
were  absent  and  no  basophilic  stippling  of  the  corpus- 
cles present,  we  should  have  evidence  against  typhoid 
and  against  lead  encephalopathy  respectively.  Sputum 
examination  would  help  to  settle  the  question  of 
tuberculosis. 

6.  What     other    examinations    should     be    made?     Spinal 

puncture,  Kernig's  sign,  Babinski's  reaction,  retinal 
examination  blood  pressure  record. 

Diagnosis:  The  intensity  of  headache  with  photophobia 
and  vomiting  suggest  organic  brain  disease.  The  onset  is 
more  sudden  than  in  most  brain  diseases,  except  meningitis. 
The  family  history  of  phthisis,  the  recent  cervical  adenitis, 
and  apical  bronchitis  with  fever  suggest  tuberculosis.  Lum- 
bar puncture  and  retinal  examination  would  settle  it. 

All  the  symptoms  here  mentioned  have  occurred  in  brain 
tumor  or  abscess,  but  in  most  cases  of  these  diseases,  focal 
symptoms  are  present  (paralysis,  aphasia,  Jacksonian  epilepsy, 
local  paraesthesia,  astereognosis)  and  the  onset  is  slower.  In 
malaria  there  is  almost  invariably  more  pyrexia,  and  in  lead 


50  CASE   HISTORIES   IN   MEDICINE. 

encephalopathy  there  are  usually  convulsions  and  evidences 
of  lead  in  other  organs. 

Meningismus  such  as  occurs  at  the  onset  of  infectious  disease 
(typhoid,  pneumonia)  is  unlikely,  on  account  of  the  severity  of 
the  headache,  the  moderate  temperature,  and  the  absence  of 
positive  evidence  of  any  such  infection.  Tuberculous  men- 
ingitis —  that  is,  acute  general  tuberculosis  with  predominance 
of  meningeal  symptoms  —  seems  the  most  probable  diagnosis. 

Prognosis  and  Treatment  (see  Case  9.) 


INFECTIOUS   DISEASES.  5I 

Case  14.  A  married  lady  of  fifty-seven,  with  a  grown 
family  of  healthy  children,  began  about  three  years  ago  to 
suffer  from  general  headaches,  during  which  she  could 
understand  and  answer  questions,  though  memory  of  what 
was  asked  and  replied  was  lost.  These  headaches  recurred 
irregularly,  each  attack  lasting  twenty-four  hours  or  more. 
Two  years  ago  her  physician  suspected  myxoedema,  and  great 
improvement  in  all  respects  followed  the  taking  of  thyroid. 
The  dosage  was  diminished  and  for  some  months  back  she 
has  taken  only  2  or  3  grains  a  day. 

About  one  month  ago  headache,  more  constant  and  less 
severe  than  formerly,  came  on,  and  she  failed  in  general 
health  and  strength  without  any  definite  symptoms  other 
than  the  headache.  Six  days  ago  she  began  to  get  stupid 
and  within  twenty-four  hours  was  in  deep  coma,  in  which 
she  still  remains.  There  is  incontinence  of  urine.  The  bowels 
have  not  moved  for  several  days.  Two  days  ago  the  pulse, 
respiration,  and  temperature  were  all  normal  at  6  a.m. 
Between  that  hour  and  9  a.m.  the  pulse  rose  to  no,  respira- 
tion to  30,  and  temperature  to  103°,  remaining  elevated  ever 
since.  Soon  after  the  advent  of  coma  the  thyroid  extract  was 
increased  to  15  grains  three  times  a  day.  Until  within  twenty- 
four  hours  she  has  taken  food  fairly  well.  Pulse  130,  regular, 
respiration  36,  temperature  102.8°.  Lies  on  back  with  flaccid, 
non-sensitive  limbs;  sides  of  face  equal;  pupils  equal,  moder- 
ately contracted,  responding  slightly  to  strong  light  stimulus; 
all  other  reflexes  absent,  except  the  plantar.  The  eye  fundus 
is  negative.  Visceral  examination  is  negative,  except  for  dul- 
ness,  bronchial  respiration,  and  fine  rales  over  the  right  lower 
back.     The  leucocytes  are  23,000  per  cu.  mm. 

1.  What  is  the  condition  of  the  right  lung?     Pneumonia, 

probably  of  the  hypostatic  type. 

2.  If  Babinski's  reaction  were  present  on  one  side,   would 

your  diagnosis  be  modified?     (See  question  4.) 

3.  Significance  of  the  mode  of  onset  in  this  case  ?     A  gradual 

onset  of  coma  is  against  cerebral  haemorrhage  or  em- 
bolism. 

4.  What  can  be  inferred  from  the  absence  of  focal  symptoms  ? 

That  there  are  probably  no  lesions  in  the  motor  areas. 
The  whole  brain  is  probably  affected  to  some  extent. 


52  CASE   HISTORIES   IN   MEDICINE. 

Diagnosis:  Cerebral  tumor  or  abscess  is  possible,  but  the 
absence  of  focal  symptoms,  and  especially  of  choked  disk, 
are  against  these  diagnoses.  Uraemia  could  explain  jail  the 
symptoms,  but  the  urine  showed  no  characteristic  changes.^ 
The  thyroid  treatment  could  not  by  itself  produce  such 
symptoms.  The  fever  and  leucocytosis  make  it  needful  to 
consider  meningitis,  but  the  gradual  onset  and  the  absence 
of  choked  disk  and  of  cranial  nerve  symptoms  are  against  it. 
Kernig's  sign  is  apparently  absent  (flaccid  limbs) ;  in  menin- 
gitis it  is  usually  present.  Cerebral  arteriosclerosis,  with  or 
w^ithout  syphilis  and  with  or  without  definite  foci  of  soften- 
ing, seemed  on  the  whole  most  likely. 

Autopsy  showed  a  "  worm-eaten  "  and  greatly  thickened 
cranium,  with  two  foci  of  softening,  narrowed  cerebral  arteries 
and  amyloid  spleen  and  kidneys.  Hypostatic  pneumonia  on 
the  right. 

Prognosis:  We  will  consider  here  the  prognosis  of  what  is 
ordinarily  known  as  "  cerebral  syphilis,"  that  is,  the  cases  with 
a  well-marked  history  or  lesions  of  syphilis  elsewhere  in  the 
body,  combined  with  the  present  and  usually  acute  suffering 
from  symptoms  which  point  to  the  brain  (coma,  delirium, 
squints,  vomiting,  headache,  and  peripheral  paralyses).  In 
cases  of  this  type,  whatever  the  precise  cerebral  lesion  may 
be,  the  prognosis  for  immediate  recovery  is  good  provided 
the  treatment  is  properly  administered.  But  the  great 
majority  of  such  patients  has  a  relapse  months  or  years 
later,  which  may  again  be  successfully  combated  or  may 
result  in  lasting  paralysis  or  in  death.  Such  patients,  even 
if  they  escape  the  more  serious  cerebral  symptoms  such  as 
are  presented  in  this  case,  are  apt  to  suffer  from  minor  mani- 
festations of  the  same  type,  presumably  because  of  what 
Pal  has  called  "  vascular  crises."  The  patient  must  expect 
to  suffer  from  more  or  less  trifling  and  transitory  attacks 
of  drowsiness,  aphasia,  Jacksonian  epilepsy,  monoplegia  or 
hemiplegia,  and  from  frequent  headaches. 

Treatment:    It  is  my  belief  that  with  the  cerebral  mani- 

^  No  mention  of  the  urine  was  made  in  the  account  of  the 
case  given  by  the  attending  physician;  hence  it  is  omitted  in 
the  history  printed  above. 


INFECTIOUS   DISEASES.  53 

festations  of  syphilis,  potassium  iodid  should  be  used  in  a 
way  very  different  from  that  which  is  most  useful  in  treating 
the  other  visceral  and  cutaneous  lesions.  Whereas  in  the 
latter  it  is  rarely,  if  ever,  advisable  to  give  more  than  50  grains 
of  potassium  iodid  a  day,  study  and  experiment  have  convinced 
me  that  in  cases  with  cerebral  manifestations,  really  brilliant 
results  are  to  be  obtained  by  rapidly  increasing  the  dose  of 
iodid  until  300  grains  a  day  are  taken.  Small  or  moderate 
doses  do  not  have  the  same  effect.  Mercury  should  also  be 
given  by  daily  inunctions,  but  its  effects  are  very  much  less 
striking. 

Aside  from  the  administration  of  these  two  drugs,  the 
treatment  is  essentially  identical  with  that  of  tuberculous 
meningitis  (see  Case  9). 

If  the  blood  pressure  is  very  high,  bleeding  or  purgation 
may  also  be  of  value. 


54  CASE   HISTORIES   IN   MEDICINE. 

Case  15.  An  unmarried  clerk  of  thirty- two,  who  was  in 
the  Philippines  and  in  Southern  China  from  1903  to  1908  was 
first  examined  ]\Iay  12,  1910.  Immediately  on  his  return 
from  the  Philippines,  in  the  fall  of  1908,  he  had  a  fever  which 
lasted  for  the  greater  part  of  four  months.  The  nature  of 
this  fever  he  does  not  know.  Since  it  left  him  he  has  felt 
very  weak,  but  has  managed  to  do  his  work  with  occasional 
short  rests.  During  the  early  months  of  his  residence  in  this 
country  he  had  catarrh. 

For  the  past  week  he  has  had  a  cold,  and  last  night  he  was 
troubled  by  wheezing  and  some  dyspnoea.  His  appetite  is 
good  and  his  bowels  regular,  but  he  is  incessantly  gaping  and 
ya^\^ling  all  da^'',  perhaps  because  his  nights  are  disturbed  by 
ner\?-ousness,  which  makes  him  start  up  from  sleep  quite 
frequently. 

His  family  history  appears  to  be  good,  though  his  sister 
died  at  eighteen  of  a  "  general  decline." 

His  present  weight,  150  pounds,  is  greater  than  at  any 
previous  time,  but  he  is  exceedingly  weak  and  nervous,  liable, 
he  says,  to  give  out  and  collapse  at  any  time. 

I.  Prior  to  physical  examination,  what  diseases  should  be 
especially  suspected  ?  In  anyone  who  has  recently 
returned  from  the  Philippines,  syphilis,  hookworm  dis- 
ease, and  amoebic  dysentery  are  suggested.  Aside 
from  these  diseases  we  should  always  suspect  incipient 
phthisis  in  a  patient  who  has  so  much  weakness  with- 
out obvious  cause,  and  especially  in  one  who  has  had 
a  prolonged,  unexplained  fever.  Neurasthenia  must 
also  be  considered  if  any  reason  for  its  occurrence  can 
be  discovered.  A  patient  with  symptoms  very  similar 
to  these  has  recently  consulted  me,  bringing  in  his  hand 
a  blood  film  made  by  another  physician,  and  showing 
unmistakable  evidences  of  lymphoid  leucaemia.  An- 
other examination  of  a  fresh  specimen  of  the  patient's 
blood,  made  as  a  control,  showed  precisely  the  same 
condition.  Such  a  control  is  necessary,  as  disastrous 
mistakes  may  occur  through  a  mix-up  of  blood  films 
in  a  laboratory.  Nephritis,  larv^al  Graves'  disease,  and 
typhoid  should  also  be  considered. 

Diagnosis:  Physical  examination  showed  crackling  rales 
and  interrupted  high-pitched  inspiration  with  slight  dulness 


INFECTIOUS   DISEASES.  55 

at  both  apices.  No  sputa  could  be  obtained  at  the  time,  but 
the  facts  seemed  to  me  to  justify  the  diagnosis  of  phthisis. 
The  further  course  of  the  case  confirmed  this  assumption. 

Prognosis:  In  a  moderately  advanced  case  like  this  the 
outlook  depends  upon  the  patient's  temperament  and  char- 
acter, upon  the  size  of  his  pocketbook,  and  upon  his  natural 
capacity  for  acquiring  immunity.  Under  ideal  conditions, 
perhaps  half  of  such  cases  may  recover,  but  it  is  likely  to  be 
a  life-long  fight. 

Treatment  (see  Case  4). 


56  CASE   HISTORIES   IN   MEDICINE. 

Case  1 6.  A  woman,  apparently  about  forty,  is  seen  at  a 
hotel  at  6  p.m.,  unconscious.  Semi-dilated  pupils,  equal  and 
responding  to  very  strong  light  stimulus.  The  face  is  pale; 
pulse  90,  regular,  small,  and  soft.  Respiration  is  shallow, 
with  an  occasional  deep  inspiration.  Temperature  normal. 
No  blood  or  froth  on  lips;  no  odor  to  breath.  No  disparity 
between  sides  of  face.  Limbs  flaccid,  but  firm  supraorbital 
pressure  causes  motion  in  one  or  another  extremity,  so  also 
firm  pinching  of  leg  muscles.  No  reflexes,  deep  or  superficial ; 
no  oedema;  no  glands.  Old,  white,  irregular  scars  seen  near 
root  of  nose,  on  forehead,  and  right  cheek.  Physical  examina- 
tion of  thorax  and  abdomen  negative.  Urine  by  catheter, 
1 01 7,  acid,  no  albumin,  no  sugar. 

In  the  absence  of  all  friends,  the  housekeeper  states  that 
the  patient  and  her  husband  came  there  from  a  neighboring 
town  the  evening  before.  The  husband  was  awakened  in 
the  night  by  some  noise  to  find  his  wife  unconscious.  Later, 
she  vomited,  but  she  has  had  no  convulsion  as  far  as  known, 
either   low  or  previously. 

1.  Important  causes  of  coma?     Apoplexy  (including  cerebral 

haemorrhage,  thrombosis,  and  embolism),  uraemia  and 
hepatic'  toxaemia,  diabetes,  cerebral  concussion  and 
compression,  syncope  (fainting),  poisoning  by  opium, 
alcohol,  and  illuminating  gas,  sunstroke,  epilepsy  (after 
the  seizure),  hysteria. 

2.  What  strong  evidence  have  we  against  opium  poisoning 

in  this  case  ?  The  effects  of  opium  kill  or  wear  off 
within  eight  hours.  This  attack  has  lasted  already 
about  eighteen  hours. 

3.  What  can  be  inferred  from  the  abolition  of  reflexes  ?     Any 

deep  coma  may  abolish  the  reflexes,  hence  we  can  infer 
from  this  fact  only  that  the  coma  is  deep. 

Diagnosis:  Uraemia,  diabetes,  and  hepatic  toxaemia  are  ex- 
cluded by  the  examination  of  the  urine,  abdomen,  and  breath; 
syncope,  alcohol,  and  opium  by  the  duration  of  the  symptoms; 
sunstroke,  concussion,  epilepsy,  compression,  and  gas  poison- 
ing by  the  history  of  the  case.  The  reflexes  are  never  wholly 
absent,  but  rather  increased  in  hysteria,  which  is  also  unlikely 
because  of  the  general  muscular  flaccidity.  Apoplexy  (in  the 
wide  sense  above  defined)  is  apparently  the  diagnosis.     The 


INFECTIOUS   DISEASES.  57 

white  scars  on  the  forehead  suggest  injuries  from  a  fall  in 
epilepsy,  also  healed  syphilitic  lesions.  The  former  explana- 
tion is  ruled  out  by  the  history;  the  latter  gives  a  very  natural 
reason  for  the  coma  and  for  the  lack  of  focal  symptoms,  which 
in  apoplexy  of  syphilitic  origin  are  often  absent. 

Prognosis:  The  majority  of  such  cases  recover  from  the 
attack  within  a  few  days  or  weeks,  especially  if  vigorous  anti- 
syphilitic  treatment  is  carried  out. 

Treatment  (see  Case  14). 


58  CASE   HISTORIES   IN   MEDICINE. 

Case  17.  A  laborer  of  twenty-nine  was  seen  March  5. 
Took  to  bed  a  week  ago  with  fever.  Now  he  looks  very  dull, 
with  lips  dusky,  tongue  dry  and  brown,  teeth  crusted  with 
sordes.  Temperature  101.5°,  pulse  100,  respiration  32.  His 
chief  complaint  is  of  nervousness  and  insomnia,  but  he  admits 
that  his  appetite  is  very  poor  and  that  he  has  vomited  several 
times  within  the  past  week.  He  denies  alcohol  and  venereal 
disease. 

Chest  negative.  Abdomen  slightly  distended,  tympanitic, 
not  tender.  Spleen  not  felt.  The  skin  is  unusually  smooth 
and  silky.  There  is  twitching  of  the  arms  and  legs  and  ten- 
derness of  the  latter.  All  his  movements  are  very  alert. 
Urine:  Normal  color,  acid,  1020,  a  trace  of  albumin,  no  sugar, 
no  diazo  reaction.  Sediment,  much  pus  (microscopic)  and 
mucus,  a  little  normal  blood.  The  Widal  reaction  and  blood 
culture  are  negative;  white  cells  16,000. 

Scattered  over  the  whole  body  are  dull  red  macules  about 
the  size  of  a  split  pea  or  smaller.     In  places  they  are  brownish. 

1.  What    explains    the    condition    of    the    mouth?     Fever, 

mouth  breathing,  and  neglect. 

2.  (a)  What  are   the   commonest  causes   of   insomnia   in  a 

laborer  of  twenty-nine  ?  (b)  In  old  age  ?  (c)  In  a 
baby?  (a)  Alcoholism.  (b)  Arteriosclerosis  and  its 
consequences;  physiologically,  the  old  sleep  much  less 
than  the  young,     (c)   Indigestion. 

Diagnosis :  The  most  distinctive  physical  signs  here  present 
are  fever  and  a  rash.  The  fever  is  moderate  and  is  said  to 
have  lasted  a  week,  but  we  cannot  judge  whether  it  was  of 
the  continued  type,  or  irregular  and  intermittent.  Nervous- 
ness, abnormally  alert  motions,  and  insomnia  are  a  trio  of 
signs  which  in  a  laborer  we  learn  to  associate  with  alcohol- 
ism and  threatened  delirium  tremens.  The  smooth  and  silky 
skin  is  another  important  though  not  constant  sign  of  alcohol- 
ism. The  denial  of  drinking  habits  is  not  important  in  the 
presence  of  four  such  evidences.  Can  alcohol  alone  cause 
fever  ?  Surely  —  and  the  fever  is  usually  moderate,  as  in  this 
case;  but  it  is  important  to  exclude  by  careful  examination 
all  infectious  processes,  especially  typhoid  and  pneumonia. 
This  has  apparently  been  done  in  this  case  and  the  diagnosis 


INFECTIOUS   DISEASES.  59 

would  seem  to  be  delirium  tremens.  The  poor  appetite  and 
vomiting  in  the  previous  week  are  then  probably  of  alcoholic 
origin. 

The  rash  is  still  unexplained.  Macules  of  this  size  and 
color,  without  itching  or  haemorrhage,  are  usually  due  to 
syphilis.  The  patient's  denial  of  infection  is  not  of  impor- 
tance and  in  this  case  was  later  shown  to  be  false.  That  the 
fever  was  in  part  of  syphilitic  origin  was  suggested  by  the 
fact  that,  when  the  other  symptoms  of  alcoholism  ceased, 
the  fever  lasted  on  for  some  days.  What  other  manifesta- 
tions of  syphilis  might  occur  at  this  time  ?  Adenitis,  mucous 
patches,  alopecia,  periostitis,  iritis.  None  of  these  appeared 
however. 

Prognosis:  For  prognosis  and  treatment  of  alcoholism  see 
Case  68.  Here  the  prognosis  and  treatment  of  syphilis  only 
will  be  considered. 

Recent  experience  with  the  Wassermann  reaction  tends  to 
make  us  believe  that  some  results  of  syphilitic  infection 
persist  in  the  body  for  the  greater  part,  if  not  the  whole,  of 
life  unless  vigorous  treatment  is  kept  up  for  years.  But 
we  must  distinguish  these  latent  and  intangible  results 
from  definite  lesions  or  symptoms  of  which  the  patient  is  in 
any  way  aware.  Judging  by  these  latter  alone,  we  may  say 
that  after  a  treatment  of  one  or  two  years  the  great  majority 
of  cases  of  syphilis  appear  to  be  permanently  cured.  Even 
in  those,  however,  in  which  very  thorough  treatment  has 
been  carried  out  and  all  visible  and  obvious  lesions  made  to 
disappear,  experience  shows  that  diseases  of  the  nervous  sys- 
tem, tabes  and  paresis,  may  later  occur,  and  there  is  no  good 
evidence  that  treatment,  even  if  prolonged  beyond  one  or  two 
years,  can  be  relied  upon  to  prevent  these  sequels. 

It  seems  to  be  an  established  fact  that  patients  whose 
general  condition  is  greatly  lowered,  either  before  the  infec- 
tion or  as  a  result  of  it,  react  very  slowly  and  imperfectly  to 
medicinal  treatment  by  mercury  and  potassic  iodid.  Prob- 
ably a  certain  proportion  of  these  stubborn  cases  can  be 
cured  by  the  use  of  Ehrlich's  new  remedy,  salvarsan,  but  it  is 
still  too  early  to  speak  positively  upon  this  matter.  In  well- 
nourished  patients  we  may  generally  predict  a  rapid  ameliora- 


60  CASE   HISTORIES   IN    MEDICINE. 

tion  of  most  of  the  manifestations  of  a  cutaneous,  mucous,  or 
visceral  lesion  within  a  few  weeks  under  treatment  by  mer- 
cury and  potassic  iodid.  With  salvarsan  the  improvement  is 
sometimes  much  more  swift. 

Treatment:  Strict  attention  to  the  general  health,  to  the 
diet,  and  the  condition  of  the  bowels,  to  exercise  and  proper 
sleep  is  important  in  all  cases,  especially  in  those  who  are 
debilitated.  Beyond  these  general  hygienic  measures,  our 
treatment  resolves  itself  into  the  methods  of  administering 
mercury,  iodid  of  potassium,  and  salvarsan.  It  should  be 
distinctly  understood  that  while  iodid  of  potassium  has 
great  value  for  causing  shrinkage  and  absorption  of  the  exu- 
dates and  tumor-like  masses  which  incommode  or  disfigure 
the  patient,  there  is  no  evidence  that  it  has  any  tendency  to 
kill  the  germ  which  produces  the  disease.  For  slaughter  of 
the  bacteria  we  must  fall  back  upon  mercury  and  salvarsan. 

Potassic  iodid  should  be  administered  in  saturated  aqueous 
solution  which  is  practically  one  grain  of  the  salt  per  drop. 
Five  drops  of  this  mixture  should  be  given  in  a  little  milk 
after  each  meal.  The  irritating  effects  of  the  drug  are  thus 
best  neutralized.  Except  in  the  cerebral  lesions  of  syphilis, 
which  have  been  discussed  above,  the  dose  of  potassic  iodid 
should  not  be  increased  beyond  15  grains  three  times  a  day. 
In  the  great  majority  of  cases  7  to  10  grains  work  as  well. 
Even  with  these  doses  a  cutaneous  rash,  a  metallic  taste 
in  the  mouth,  and  other  disagreeable  symptoms  are  not  in- 
frequently produced.  The  belief  that  large  doses  hurry  the 
cure  of  the  disease  is,  except  in  cerebral  cases,  ill  founded. 

Regarding  the  length  of  time  during  which  KI  should  be 
given  something  will  be  said  below.  There  is  no  demonstrable 
advantage  in  administering  iodin  in  the  form  of  one  of  its 
other  salts  or  in  any  of  the  other  proprietary  and  widely- 
advertised  mixtures  now  upon  the  market.  The  old-fash- 
ioned potassium  iodid  is  just  as  good  and  much  cheaper. 

Mercury,  the  great  germ  killer  in  syphilis,  acts  much  more 
slowly  than  KI,  but  is,  on  the  whole,  the  more  important  of 
the  two  drugs.  The  best  way  of  giving  it  in  the  majority 
of  cases  is  by  inunction.  A  lump  of  mercurial  ointment,  the 
size  of  a  large  pea,  is  taken  in  the  palm  of  the  hand  and  rubbed 


INFECTIOUS  DISEASES.  6l 

into  the  skin  until  no  considerable  residue  is  left.  This  re- 
quires as  a  rule  about  half  an  hour  of  rubbing.  A  different 
portion  of  the  skin  should  be  selected  each  night;  first  one 
side  of  the  chest,  then  the  other,  then  the  upper  portion  of 
one  leg,  then  the  corresponding  portion  of  the  other  leg,  next 
the  lower  leg,  and  so  on,  until  upon  the  seventh  night  one 
returns  to  the  portion  first  employed.  The  advantage  of 
carrying  out  the  inunction  each  night  is  that  a  certain  amount 
of  the  mercury  is  absorbed  during  sleep.  The  remainder  can 
be  washed  off  in  the  morning,  and  the  patient  enjoy  a  reason- 
able cleanliness  until  the  next  night. 

Patients  who  desire  to  keep  their  diseases  secret  can  rarely 
use  this  method  of  administering  the  drug,  unless  at  a  sana- 
torium or  hospital.  It  is  on  the  whole,  nevertheless,  the  best 
method,  for  it  combines  perfect  safety  with  great  efficiency, 
and  a  minimum  of  gastro-intestinal  irritation.  In  Europe  sub- 
cutaneous injections  are  very  widely  used.  They  have  the 
advantage  of  saving  trouble  and  protecting  the  patient  from 
discovery.  On  the  other  hand,  they  are  painful  and  occa- 
sionally dangerous.  On  the  whole  the  most  useful  prepara- 
tion for  subcutaneous  use  is  that  known  as  enesol,  in  which 
arsenic  is  combined  with  the  mercury.  ^  grain  of  this 
substance  is  injected  deeply  into  the  muscle  at  intervals  of 
about  seven  days.  Others  use  corrosive  sublimate,  one  grain 
dissolved  in  two  drams  each  of  glycerin  and  distilled  water, 
5  to  15  minims  being  injected  every  two  or  three  days.  These 
preparations  are  on  the  whole  preferable  to  the  insoluble 
preparations,  despite  certain  advantages  of  the  latter. 

The  drug  may  also  be  administered  by  mouth.  This  is 
the  simplest  and  most  time-saving  of  all  methods,  but  is  less 
reliable  and  more  apt  to  cause  gastro-intestinal  irritation. 
The  salt  chosen  does  not  seem  to  be  a  matter  of  any  great 
importance.  As  convenient  as  any  is  the  use  of  corrosive 
sublimate,  from  a  thirty-sixth  to  a  twenty-fourth  of  a  grain, 
in  pill  form,  taken  three  times  a  day  after  meals. 

Whatever  form  of  mercury  is  used,  the  patient  must  be 
instructed  to  give  special  attention  to  the  care  of  the  teeth 
and  gums,  brushing  and  rinsing  them  several  times  a  day  in 
order  to  prevent  inflammation  with  the  resultant  salivation. 


62  CASE   HISTORIES   IN   MEDICINE. 

As  soon  as  there  is  the  least  soreness  or  lameness  on  striking 
the  teeth  together  the  drug  must  be  discontinued,  and  not 
taken  again  until  all  soreness  has  departed.  If  we  are  warned 
by  this  early  danger  signal  we  shall  rarely  get  a  troublesome 
stomatitis. 

Salvarsan  should  probably  be  reserved  for  the  severer  and 
more  obstinate  cases,  and  for  those  in  which  mercurial  treat- 
ment has  proved  a  failure,  or  is  for  some  reason  or  other  im- 
possible. The  intramuscular,  and  the  intravenous  methods 
of  administration  have  each  their  warm  advocates,  and  I  do 
not  feel  prepared  to  decide  between  them.  In  any  case  the 
preparation  of  the  crude  drug  for  injection  requires  an  apothe- 
cary of  some  experience.  The  dose  given  by  the  intravenous 
method  is  usually  .5  gram  and  by  the  intramuscular  .6  gram. 
As  a  rule  only  one  dose  is  administered,  and  we  then  await 
developments.  Possibly  no  second  dose  will  be  required,  but 
in  the  majority  of  cases  this  expectation  is  not  fulfilled. 
Treatment  should  be  persisted  in  until  the  Wasserman  re- 
action remains  constantly  absent.  This  means  as  a  rule 
many  njonths  of  treatment.  Probably  it  is  safer  to  resume 
treatment  after  one  or  two  years  of  abstinence,  and  to  submit 
the  patient  to  short  courses  of  mercury  or  salvarsan  at  inter- 
vals throughout  his  life. 


INFECTIOUS   DISEASES.  63 

Case  18.  A  young  man  of  twenty-one  is  seen  January  lo. 
At  the  age  of  twelve  he  had  very  severe  scarlet  fever,  followed 
by  endocarditis,  for  the  results  of  which  he  was  under  medical 
care  for  about  three  years.  Of  recent  years  his  health  has 
been  very  good  and  he  has  ridden  the  wheel  fast  and  far 
without  inconvenience.  Rather  more  than  two  months  ago 
he  went  to  the  doctor's  office  with  a  "  cold  ";  temperature 
normal.  A  few  days  later  he  returned  with  a  temperature 
of  103°,  and  said  he  had  had  night  sweats.  He  was  sent  home, 
sat  about  the  house  for  two  days,  and  then  took  to  his  bed, 
which  he  has  not  left  since.  A  four-hourly  chart  has  been 
kept  for  sixty-two  days,  and  shows  a  continuous  fever,  rang- 
ing from  101°  to  104°,  usually  higher  in  the  afternoon.  On  the 
seventh  and  tenth  days  after  taking  to  his  bed  he  had  nose- 
bleed. This  he  had  occasionally  when  well.  Cough  has  been 
a  fairly  constant  though  not  prominent  symptom,  and  twice 
has  led  to  vomiting.  The  bowels  have  been  regular  with 
the  aid  of  an  occasional  enema.  Delirium  has  been  practically 
absent.  Early  in  his  illness  there  were  a  few  doubtful  rose 
spots.  The  spleen  has  never  been  palpable.  He  has  once  or 
twice  complained  of  some  pain  in  his  shoulders,  but  has  had 
no  other  articular  symptoms. 

The  pulse  was  about  90  at  first,  regular,  of  good  strength. 
It  has  lately  become  irregular  and  rapid,  some  of  the  heart 
beats  not  reaching  the  wrist.  Under  digitalis,  brandy,  and 
strychnia,  the  pulse  has  improved  very  much  and  is  now 
regular,  100.  Ever  since  he  took  to  his  bed  he  has  been  on 
an  exclusive  milk  diet.  The  urine  is  sufficient  in  quantity 
with  a  large  trace  of  albumin,  granular  and  hyalin  casts, 
specific  gravity   1015. 

The  patient  is  pale,  lies  on  his  back,  is  not  much  emaciated, 
has  a  clean  tongue,  and  complains  only  of  weakness. 

On  physical  examination  the  lungs  seem  clear.  The  heart's 
impulse  is  in  the  fifth  space,  half  an  inch  to  the  left  of  the 
nipple.  A  systolic  murmur  is  heard  with  maximum  intensity 
over  the  impulse,  transmitted  into  the  axilla.  Inside  the 
left  nipple  is  a  doubtful  presystolic  murmur.  The  pulmonic 
second  sound  is  accentuated,  aortic  second  sound  clear.  The 
belly  is  slightly  distended,  duller  at  the  flanks  than  in  the 


64  CASE  HISTORIES   IN   MEDICINE. 

center,  the  dulness  and  resonance  shifting  somewhat  with 
change  of  position.  The  blood  shows  a  moderate  leucocytosis 
and  no  Widal  reaction. 

1.  In   what   diseases   do   night   sweats  occur?     Those  pro- 

ducing fever,  prostration,  or  both:  phthisis,  syphiHs, 
rheumatism,  pneumonia,  and  typhoid  (especially  in 
convalescence),  septicaemia  in  all  forms,  alcoholism, 
neurasthenia,  and  others. 

2.  Significance   of   the   cough   in   this   case?     The   common 

causes  of  cough  are  {a)  irritations  of  the  upper  air 
passage;  (6)  any  disease  of  the  lungs;  and  (c)  any  dis- 
ease of  the  heart  that  produces  pulmonary  stasis.  In 
this  case  there  are  no  evidences  of  (a)  or  of  (&).  Hence 
we  fall  back  on  (c),  pulmonary  stasis  due  to  the  heart 
lesion  above  described. 

3.  How  is  your  diagnosis  affected  by  the  third  (short)  para- 

graph printed  above?  Doctors  sometimes  conclude 
from  such  evidence  that  no  serious  disease  is  present. 
This  conclusion,  however,  is  quite  unjustifiable  when 
the  physical  signs  belie  it.  Hence  the  importance  of 
accurate  and  thorough  physical  examination. 

4.  Name  three  common  fevers  which  may  run  for  weeks  with- 

out touching  normal.  Typhoid,  tuberculosis,  septi- 
caemia (with  or  without  septic  endocarditis). 

5.  What  further  valuable  evidence  might  be  obtained  from 

the  blood?     Blood  cultures  should  be  made. 

6.  Why  is  the  specific  gravity  of  the  urine  so  low  ?     Exclusive 

and  profuse  milk  diet. 

7.  If  the  spleen  had  become  palpable,  how  should  the  diag- 

nosis have  been  modified  ?  Not  at  all,  since  all  the 
diseases  to  be  considered  here  may  produce  splenic 
enlargement. 

8.  What  further  symptoms  might  appear  which  would  clinch 

the  diagnosis  ?  Evidence  of  embolism,  commonest  in 
the  spleen  and  kidney,  rarer  in  brain,  extremities,  or 
subcutaneous  tissues. 

Diagnosis:  Typhoid  after  sixty- two  days  of  fever  is  almost 
sure  to  show  a  Widal  reaction  and  no  leucocytosis.  Tuber- 
culosis of  this  duration  should  show  more  evidence  of  cerebral, 
pulmonary,  or  other  local  lesions.  Pure  tuberculous  peri- 
tonitis would  produce  the  abdominal  signs  here  described, 
but  rarely  if  ever  produces  such  fever  and  would  not  account 
for  the  cardiac  signs.  Septicaemia  with  septic  endocarditis 
will  account  for  all  the  facts  of  the  case.     The  ascites  was 


INFECTIOUS   DISEASES.  65 

apparently  due  (like  the  cough)  to  heart  weakness.  The 
acute  mitral  endocarditis  was  proved  at  autopsy  to  be  en- 
grafted (as  the  previous  history  suggests)  upon  an  old  process 
of  like  nature.  Multiple  embolic  infarctions  of  the  spleen 
and  kidney  were  present. 

-  Prognosis:  The  outlook  in  cases  of  endocardial  fever  per- 
sisting more  than  three  weeks  is  usually  bad.  It  is  almost 
invariably  fatal  when  bacilli  can  be  recovered  from  the  cir- 
culating blood  (see  the  article  by  Libman,  Transactions  of 
the  Association  of  American  Physicians,  1910,  page  5).  It 
thus  appears  that  the  results  of  blood  culture  are  very  im- 
portant in  prognosis,  though  they  help  us  very  little  either 
for  diagnosis  or  for  treatment.  Probably  in  a  larger  series  of 
cases  Libman's  utterly  hopeless  outlook  for  all  showing  bac- 
teriaemia  would  not  be  maintained.  Presumably  some  cases 
of  this  group  will  recover,  but  they  must  be  very  few.  If 
bacilli  are  not  found  in  the  peripheral  circulation,  a  recovery 
is  always  possible,  especially  within  the  first  three  weeks  of 
continued  fever. 

The  excellent  condition  in  which  the  patient  usually  remains 
throughout  the  larger  part  of  his  illness,  confirms  the  results 
of  animal  inoculation,  in  showing  that  the  virulence  of  the 
organism  is  not  intense,  although  for  some  reason  it  seems  to 
be  one  against  which  the  patient  can  form  no  antibody,  but 
is  gradually  worn  out  in  the  struggle.  The  cases  which  re- 
cover usually  suffer  for  a  number  of  weeks,  and  are  left  in  an 
emaciated  and  feeble  condition  for  some  months.  There  is 
always  a  marked  tendency  to  relapse  when  the  heart  valves 
are  the  site  of  chronic  endocarditis. 

Treatment:  Medication  has  so  far  proved  useless.  None 
of  the  antitoxins  or  vaccines,  none  of  the  drugs  yet  tried  have 
shown  any  power  to  arrest  the  disease  or  to  modify  its  course 
appreciably.  We  are  reduced,  therefore,  to  hygienic  manage- 
ment which  is  usually  very  simple,  as  the  patient  is  obviously 
better  off  in  bed,  and  can  usually  digest  and  absorb  all  the 
ordinary  foodstuffs.  As  in  all  infections  the  windows  of  the 
patient's  room  should  be  kept  open  day  and  night  and  his 
bowels  properly  regulated.  If  the  fever  is  high  a  sponge 
bath  given  as  in  typhoid  fever  may  be  a  relief  and  help  to 
conserve  his  strength  by  assisting  nutrition  and  sleep. 


66  CASE  HISTORIES   IN   MEDICINE. 

Case  19.  A  male  nurse,  thirty-three  years  old,  with  a 
negative  family  history,  is  seen  May  5.  Except  for  typhoid 
fever  nine  years  ago,  his  past  history  was  unimportant.  His 
general  health  has  always  been  good.  About  the  24th  of 
March  he  caught  cold  and  suffered  from  malaise,  loss  of 
appetite,  and  a  slight  cough  which  confined  him  to  the  house, 
but  he  did  not  send  for  a  doctor  until  March  30.  On  that 
day  he  felt  much  sicker  and  had  pain  all  over.  It  was 
especially  noticed  in  the  lower  part  of  his  right  axilla,  but  was 
not  very  severe.  His  cough  became  very  troublesome,  and 
was  accompanied  by  a  tenacious  sputum  streaked  with  blood. 
For  the  next  two  or  three  days  he  was  nauseated  and  vomited 
frequently.  A  four-hourly  chart  showed  a  temperature  vary- 
ing between  101-2°  and  104°.  The  respirations  were  36,  and 
the  pulse  120.  Signs  of  marked  consolidation  were  found  at 
the  right  base.  On  April  8,  the  temperature  had  returned  to 
normal  by  lysis,  and  there  was  a  coincident  fall  in  the  pulse 
to  90  and  in  the  respirations  to  24.  That  afternoon  intense 
pain,  much  increased  by  respiration,  came  on  in  the  lower 
part  of  the  right  chest.  The  temperature,  pulse,  and  respira- 
tion again  rose  to  their  former  height.  The  severe  symp- 
toms subsided  after  a  few  days,  but  the  temperature  has 
remained  elevated,  varying  between  99^^°  and  101°,  with 
evening  exacerbations.  The  respirations  have  never  fallen 
below  26,  nor  the  pulse  below  no.  He  has  lost  considerable 
weight.  When  seen  on  May  5,  the  patient  was  sitting  in  a 
wheel  chair.  He  was  pale,  thin,  with  flushed  cheeks,  and 
looked  sick.  The  examination  of  the  chest  showed  marked 
dulness  merging  rapidly  into  flatness  below  the  fourth  rib 
on  the  right  side  in  front,  and  from  two  inches  below  the 
spine  of  the  scapula  behind.  Over  this  area,  voice  and 
respiration  were  bronchial  in  character  but  diminished  in 
intensity,  and  numerous  coarse  and  medium  moist  rales  were 
heard.  Fremitus  was  diminished  over  the  upper  portion, 
absent  below.  The  right  border  of  the  heart  was  not  deter- 
mined. The  left  extended  beyond  the  nipple  line.  The  apex 
was  in  the  fifth  space  one-half  inch  outside  the  nipple.  The 
pulmonic  second  sound  was  accentuated.  Physical  examin- 
ation otherwise  negative.     Whites   17,000.     Tubercle  bacilli 


INFECTIOUS   DISEASES.  67 

were  not  found  in  the  sputum,  which  was  rather  copious  and 
mucopurulent  in  character.  Urine  1030,  acid,  shghtest  pos- 
sible trace  of  albumin.     Sediment  not  examined. 

Diagnosis:  The  interpretation  of  this  patient's  symptoms 
seems  to  be  as  follows:  The  initial  symptoms  were  pre- 
sumably those  of  lobar  pneumonia  which  ran  the  ordinary 
course  of  that  disease  up  to  the  8th  of  April.  With  the 
return  of  fever  the  pulmonary  signs  became  more  decidedly 
those  of  fluid  in  the  pleural  cavity,  and  this  with  the  emaci- 
ation, leucocytosis,  and  the  absence  of  tubercle  bacilli  in  the 
sputum  points  to  a  postpneumonic  empyema  presumably  of 
the  ordinary  extra-pulmonary  type  and  not  confined  between 
the  lobes. 

Prognosis:  With  prompt  and  skilful  surgical  treatment 
almost  every  case  of  this  disease  recovers  completely.  In- 
deed the  prognosis  is  much  better  than  in  serous  effusions, 
because  the  latter  have  usually  tuberculosis  in  the  back- 
ground while  purulent  effusions  are  practically  always  due  to 
the  pneumococcus.  In  postpneumonic  empyema  promptly 
and  efficiently  drained  we  can  look  for  complete  recovery 
in  the  course  of  two  to  four  months.  If  drainage  is  in- 
sufficient or  is  not  established  until  the  pus  has  remained 
for  many  weeks  in  contact  with  the  lung,  it  may  be  a  very 
slow  and  difficult  matter  to  heal  up  the  inflamed  pleural 
cavity  and  to  obtain  full  distention  of  the  compressed  lung, 
but  with  proper  attention  on  the  part  of  the  attending  phy- 
sician there  should  be  no  long  interval  between  the  beginning 
of  the  purulent  process  and  the  establishment  of  drainage. 
Under  these  conditions  practically  every  case  should  get 
wholly  well. 

Treatment :  Occasional  patients  provide  drainage  for  them- 
selves through  the  bronchial  tract.  Still  more  rarely  this 
drainage  is  efficient.  In  the  great  majority  of  cases  one  or 
two  ribs  should  be  excised  and  surgical  drainage  established 
as  promptly  as  possible.  There  is  no  medical  treatment  of 
these  cases. 


68  CASE  HISTORIES  IN   MEDICINE. 

/  ■  • 

L  Case  20.  A  physician,  fifty-one  years  old,  is  seen  Jan- 
uary 15.  Has  had  rheumatism  off  and  on  since  childhood, 
but  no  cardiac  symptoms;  has  walked  a  great  deal  and  has 
done  a  large  practice  without  a  carriage.  November  17,  he 
began  to  have  chills  and  sweating  at  irregular  intervals,  but 
kept  at  work  until  December  27,  when  he  had  sudden  pain 
in  the  left  leg,  followed  by  some  coldness  and  numbness. 

Since  December  30,  there  has  been  fever  from  99.5°  to 
103°,  with  irregular  chills.  Few  days  ago,  siezed  with  pain 
in  right  arm,  and  the  pulse  was  not  to  be  felt  in  that  wrist. 
Also  a  transitory  blindness  in  right  eye.  Pulse  72,  regular, 
good  strength.  Presystolic  murmur  at  apex.  No  cardiac 
enlargement  or  other  abnormalities.  Arms  and  legs  now 
warm.  The  patient  is  bright  and  not  feeling  very  sick.  Spleen 
slightly  enlarged,  palpable,  tender.  Some  doubtful  rose  spots. 
At  the  right  base  behind,  a  patch  of  bronchial  breathing  about 
the  size  of  an  apple  with  crackling  rales  and  increased  voice 
sounds.     No  distinct  dulness.     Urine  said  to  be  negative. 

1.  Common  causes  of  true  chills?     Malaria,   sepsis,   tuber- 

culosis, the  onset  of  any  infection,  neurasthenia. 

2.  In  what  diseases  besides  malaria  may  chills  recur  daily 

at  the  same  hour?     Sepsis,  tuberculosis. 

3.  Types  of-   thrombosis?     Puerperal,  infectious    (typhoid), 

post-operative,  marantic,  those  seen  in  cardiac  disease, 
and  those  of  unknown  cause. 

4.  Causes  of  presystolic  murmurs?     Mitral  stenosis,  "  Flint's 

murmur  "  in  aortic  regurgitation,  tricuspid  stenosis,  ad- 
hesive pericarditis. 

5.  What  symptoms  not  here  mentioned   should  you  expect 

to  see  sooner  or  later  in  this  case?     Purpura,  emaci- 
ation, diarrhoea,  and  mental  symptoms. 

6.  What  should  you  tell  the  patient  about  his  condition? 

Nothing  unless  he  forced  the  issue.     Then  the  prog- 
nosis as  given  below. 

Diagnosis:  A  long-continued  fever  with  chills,  embolic 
phenomena,  and  a  cardiac  murmur  suggest  at  once  an  infec- 
tive endocarditis,  whether  "  malignant  "  or  not  remains  to  be 
seen  (see  prognosis  in  Case  18).  Emboli  appear  to  have 
lodged  in  the  arteries  of  the  left  leg,  right  arm,  right  eye, 
spleen,  and  lung  (bronchopneumonia).  The  "  rose  spots  "  are 
skin-emboli.     In  view  of  the  "  rheumatic  "  history  we  may 


INFECTIOUS   DISEASES.  69 

suppose  that  the  acute  endocarditis  was  here  engrafted  on  a 
chronic  process.  Blood  examination  showed  a  marked  leu- 
cocytosis  and  no  Widal  reaction.  The  urine  showed  the 
ordinary  evidences  of  an  infectious  process. 

Prognosis:  Recovery  is  quite  possible  (see  above,  Case  18) 
but  not  likely.  The  symptoms  may  continue  for  weeks  or 
months  and  finally  cease  or  kill.  Between  mild  and  malig- 
nant processes  there  are  intermediate  types  of  all  degrees  of 
severity. 

Treatment  (see  above,  Case  i8). 


70  CASE  HISTORIES   IN   MEDICINE. 

Case  21.  A  coachman,  forty- two  years  old,  of  good  family 
history,  is  seen  April  20.  Health  has  always  been  good 
except  for  a  severe  attack  of  pneumonia  three  years  ago, 
which  was  followed  by  phlebitis  in  the  left  femoral  vein. 
The  left  leg  has  remained  somewhat  swollen,  and  has  been 
tense  and  slightly  painful  toward  night.  It  has  caused  rather 
more  discomfort  than  usual  during  the  past  few  days.  Yes- 
terday morning  he  got  up  feeling  as  usual,  but  on  reaching 
the  house  of  his  employer  felt  nauseated  and  had  some 
diarrhoea,  which  continued  during  the  day.  He  felt  feverish 
and  weak.  Went  to  work  again  this  morning,  but  gave  up 
after  half  an  hour  owing  to  nausea  and  pain  in  the  lower 
abdomen,  and  went  to  bed.  At  eleven  o'clock  had  a  distinct 
chill. 

Was  seen  for  the  first  time  at  12.45  p.m.  The  patient 
was  a  stout  man  who  looked  acutely  sick.  The  chest  was 
negative.  Owing  to  a  thick  fat  layer,  examination  of  the 
abdomen  was  not  altogether  satisfactory;  it  was  somewhat 
distended  and  tympanitic  and  there  was  considerable  tender- 
ness over  the  lower  portion  below  the  level  of  the  iliac  crests, 
but  no  area  of  special  tenderness,  nor  could  a  tumor  be  felt 
anywhere.  The  left  leg  was  somewhat  larger  than  the  right 
throughout.  The  skin  below  the  knee  pitted  slightly  on 
pressure.  There  was  a  little  tenderness  over  the  femoral 
ring.  The  temperature  was  then  103°,  pulse  no,  respira- 
tions 26.  At  3  P.M.  urgent  summons  was  received  to  call 
immediately  as  the  patient  had  had  a  convulsion,  was  breath- 
ing rapidly  and  with  great  difficulty,  and  was  very  cyanotic. 

1.  What   are    the    commonest   causes    of   cyanosis?     Heart 

disease  (valvular  or  parietal),  emphysema,  pneumonia, 
asthma,  methaemoglobinsemia  (usually  from  acetanilid 
in  headache  powders) . 

2.  What  important  data  do  you  miss  in  the  account  of  this 

case  ?     A  leucocyte  count  and  urinary  examination. 

3.  Do  you  expect  a  leg  to  remain  swollen  three  years  after 

an  attack  of  phlebitis?  Yes;  the  leg  does  not  often 
regain  its  normal  size. 

Diagnosis:  The  symptoms  at  the  first  visit  were  very 
indecisive.     Diarrhoea,   nausea,   abdominal   pain  with   fever 


INFECTIOUS   DISEASES.  7 1 

and  weakness  suggest  nothing  more  than  acute  gastro- 
enteritis, and  even  the  tenderness  found  in  the  lower  abdomen 
is  not  distinctive.  Peritonitis  (possibly  from  appendicitis) 
was  considered.  But  the  history  of  an  old  femoral  throm- 
bosis and  the  tenderness  over  the  femoral  ring  lead  us  to 
think  that  the  thrombus  may  have  progressed  up  into  the 
abdominal  veins,  and  to  interpret  the  later  pulmonary  symp- 
toms (sudden  onset  of  dyspnoea  and  cyanosis)  as  pulmonary 
embolism  from  the  thrombosed  abdominal  veins.  Autopsy 
showed  this  condition. 

Prognosis:  Most  cases  of  phlebitis  in  the  veins  of  the 
lower  extremity  recover  completely  in  the  course  of  a  few 
weeks  or  at  most  a  few  months.  The  leg  is  apt  to  swell  more 
or  less  throughout  the  rest  of  his  life,  if  the  patient  is  much 
on  his  feet,  since  the  collateral  circulation  is  not  the  equal 
of  that  provided  by  nature.  Nevertheless,  accidents  such  as 
occurred  in  the  case  just  quoted  are  very  rare  and  so  far  as 
I  know  cannot  be  prevented  or  warded  off. 

Treatment  then  is  confined  to  the  management  of  the 
acute  stages  of  the  disease  and  essentially  to  the  relief  of 
pain.  We  know  of  no  way  of  hurrying  the  process  of  recov- 
ery, but  we  can  make  the  patient  much  more  comfortable 
by  applying  either  heat  or  cold  to  the  affected  part.  As  a 
rule  heat  gives  much  more  relief  than  cold,  and  should  be 
applied  in  the  form  of  flaxseed  poultices  which  are  changed 
as  soon  as  they  begin  to  get  cold,  and  not  after  a  fixed  period. 

It  is  of  the  utmost  importance  to  caution  the  nurse,  the 
patient,  and  his  friends  against  the  dangers  of  any  massage 
applied  to  the  region  of  the  blocked  vein.  I  have  known 
sudden  death  to  follow  such  massage  in  two  cases,  the  clot 
being  apparently  detached  and  blocking  a  large  pulmonary 
vein  as  in  the  case  now  under  discussion.  It  is  difficult  to 
give  any  good  reason  for  our  decision  when  to  let  the  patient 
get  up  and  move  about.  As  a  rule  we  keep  him  quiet  in  bed 
until  there  is  no  tenderness  over  the  inflamed  vein  and  little 
or  no  induration  along  it.  Nevertheless  the  "  end  reaction  " 
is  never  as  sharp  as  one  could  wish  it,  and  many  people  carry 
a  more  or  less  indurated  cord  marking  the  site  of  the  old 
phlebitis  throughout  life. 


72  CASE  HISTORIES   IN   MEDICINE. 

Case  22.  A  painter,  twenty- three  years  old.  Family  his- 
tory negative.  General  health  always  good.  Clap  eight 
months  ago,  a  slight  mucopurulent  discharge  still  persisting. 
Seven  months  ago  had  an  attack  of  colic,  lasting  three  or  four 
days,  similar  to  his  present  trouble,  but  less  severe.  Bowels 
move  once  daily  without  medicine.  Seven  days  ago  began 
to  have  cramps  which  have  grown  rapidly  worse  since  and 
have  been  only  partially  relieved  by  large  doses  of  morphia 
and  atropin.  The  abdomen  at  first  was  generally  tender, 
especially  just  to  the  right  of  the  navel.  The  bowels  have 
been  constipated  from  the  start,  in  spite  of  repeated  doses 
of  salts  and  enemata.  Very  little  gas  passes  per  rectum. 
Has  vomited  three  times,  the  vomitus  containing  nothing  of 
note. 

Physical  examination  shows  a  poorly-nourished  man,  suffer- 
ing acutely  from  general  colicky  pains  in  abdomen.  Expres- 
sion pinched,  anxious.  No  jaundice.  Faint  line  of  grey- 
black  dots  on  the  free  margin  of  the  gums.  Radial  arter- 
ies slightly  thickened.  Heart  and  lungs  normal.  Abdomen 
distended,  and  tympanitic.  Between  the  attacks  of  pain  no 
marked  tenderness  is  elicited  even  on  fairly  deep  pressure. 
The  distended,  moving  coils  of  intestine  are  visible  through 
the  thin  walls,  which  are  somewhat  rigid  everjovhere.  The 
finger  high  up  in  rectum  strikes  a  tender  point  a  little  to 
the  right  of  the  median  line.  The  pulse  is  small,  129,  and 
has  been  steadily  rising.  The  temperature,  taken  only  dur- 
ing the  past  five  days,  has  never  gone  above  99°.  Urine 
scanty,  high  colored,  acid,  specific  gravity  1026.  No  sugar, 
no  albumin.  Sediment  negative.  Leucocytes  five  days  ago 
35,000,  now  19,000. 

1.  Common  causes  of  oliguria?     Obstruction  (prostatic,  can- 

cerous, or  calculous),  nephritis,  infectious  fevers,  star- 
vation (including  pyloric  obstruction  with  gastric  dila- 
tation), vomiting,  diarrhoea,  sweating,  low  proteid  diet, 
hysteria. 

2.  How  does  the  temperature  record  influence  our  diagnosis 

here  ?  By  itself  it  would  incline  us  to  believe  that  no 
inflammatory  process  is  going  on. 

3.  Significance  of   the  leucocytosis  here  present?     Uncom- 

plicated plumbism  never  produces  such  a  leucocytosis; 


INFECTIOUS   DISEASES.  73 

intestinal  obstruction  rarely  raises  the  count  to  35,000. 
A  focus  of  inflammation  is  probably  indicated. 

4.  Have  the  thickened  radials  any  connection  with  the  other 

symptoms  of  this  case  ?  Lead  poisoning  the  patient 
certainly  has.  Lead  is  said  to  produce  thickening  of 
the  arterial  walls. 

5.  What  organs  and  tissues  are  injured  in  plumbism?     The 

gums,  the  blood,  the  nerves  supplying  the  extensors, 
the  brain,  the  arteries,  the  kidneys,  the  gastro-intes- 
tinal  tract  (colic,  constipation). 

Diagnosis:  Operation  showed  general  peritonitis  due  to 
appendicitis.  The  purgation  probably  did  great  harm.  The 
obvious  presence  of  plumbism  led  to  a  disastrous  mistake  in 
diagnosis. 

Prognosis :  So  much  has  been  written  on  the  prognosis  and 
treatment  of  appendicitis  that  I  shall  consider  this  subject 
rather  briefly  here.  The  prognosis  may  be  said  to  depend 
first,  on  the  virulence  of  the  infection,  and  second,  upon  the 
time  when  efficient  treatment  is  begun. 

The  first  of  these  factors  calls  for  no  special  comment. 
Suffice  it  to  say  that  there  are  cases  which  hurry  the  patient 
into  his  grave,  despite  all  that  can  be  done  by  early,  prompt, 
and  efficient  treatment.  In  the  vast  majority  of  cases,  how- 
ever, nature  succeeds  in  walling  off  the  inflammatory  process 
and  in  bringing  about  an  arrest  or  cure  of  the  disease.  This  is 
especially  favored  by  the  treatment  about  to  be  mentioned. 
Taking  all  cases  of  the  acute  form  of  the  disease  as  seen  at 
the  Massachusetts  General  Hospital,  the  mortality  is  about 
6%.  In  the  sub-acute  relapsing  or  chronic  cases  there  should 
be  no  mortality  if  operation  is  undertaken  at  the  right  time, 
and  with  adequate  technique. 

Treatment:  Our  action  should  be  guided  by  information 
which  tells  us  whether  the  patient  is  getting  better  or  getting 
worse  at  the  time  when  he  is  seen.  This  means  that  we  should 
see  the  patient  twice,  with  an  interval  of  several  hours  inter- 
vening, and  record  the  temperature,  the  pulse,  the  leucocyte 
count,  and  the  condition  of  the  abdominal  walls  at  each  visit. 
If  the  temperature  and  pulse  are  falling,  the  leucocyte  count 
decreasing,  the  amount  of  tenderness  and  spasm  lessening, 
we  have  every  reason  to  postpone  operation  and  await  de- 


74  CASE   HISTORIES   IN   MEDICINE. 

velopments.  If,  on  the  contrary,  the  temperature,  pulse, 
leucocyte  count,  tenderness,  and  spasm  are  increasing,  or  if 
the  patient  is  getting  worse  in  most  of  these  respects,  operation 
should  usually  be  advised.  If  it  is  impossible  to  secure  com- 
parative records  such  as  have  just  been  suggested,  and  if  one's 
decision  must  be  made  once  and  for  all  at  a  single  visit,  one 
must  endeavor  to  make  up  one's  mind  from  the  history  and 
the  observations  of  others,  whether,  in  all  probability,  the 
case  is  getting  better  or  worse.  According  to  the  impression 
thus  formed  one's  judgment  is  determined.  There  are,  how- 
ever, certain  alterations  and  exceptions  to  the  rules  just  laid 
down. 

In  the  first  place,  if  the  patient  is  getting  worse,  but  has 
not  as  yet  been  properly  treated,  one  may  delay  the  decision 
until  there  has  been  opportunity  to  try  what  can  be  done 
by  some  sensible  plan  of  management.  If,  for  example,  the 
patient  has  been  moving  about  and  receiving  food,  one  may 
reserve  judgment  until  he  has  been  put  to  bed  and  starved 
for  a  short  time.  If  these  measures,  with  the  application  of 
a  hot  sterile  poultice  fail  to  improve  his  condition,  as  shown 
by  any  of  the  tests  above  mentioned,  within  a  reasonable 
period,  operation  is  again  advisable. 

When  a  patient  has  previously  been  given  morphin  or 
some  other  opiate,  a  delusive  appearance  of  improvement, 
especially  as  regards  pain  and  tenderness,  may  be  presented. 
We  must  be  on  our  guard  against  being  deceived  in  this  way. 
It  is  most  important  that  the  patient's  pain  should  not  be 
relieved,  since  that  pain  furnishes  the  most  valuable  of  all 
guides  by  its  waxing  and  waning,  and  by  the  area  over  which 
elicited  on  pressure.  Our  judgment  regarding  the  advis- 
ability of  operation  should  always  be  influenced  by  what  we 
know  of  the  skill  and  the  experience  or  non-experience  of  the 
surgeon  available.  With  only  a  mediocre  surgeon  available 
one  may  advise  delay  in  a  case  which  would  call  for  immediate 
operation  were  any  expert  surgeon  at  hand. 

Finally,  we  must  always  take  account  of  the  individual 
factors  such  as  temperament,  sex,  and  previous  knowledge 
and  dread  of  the  disease.  A  high-strung  girl,  thoroughly 
acquainted   with   the   natural   history   of   appendicitis,   may 


INFECTIOUS   DISEASES.  75 

deceive  even  the  elect  into  believing  that  she  is  suffering  from 
this  disease,  when  in  fact  nothing  of  the  kind  is  going  on.  If 
operation  is  delayed,  the  treatment  by  supervision  and  poul- 
tices is  best  fitted  for  all  cases,  except  those  showing  evidence 
of  general  peritonitis.  Morphia  should  never  be  given  unless 
the  patient's  life  is  altogether  despaired  of. 


76  CASE   HISTORIES   IN   MEDICINE. 

Case  23.  An  electrician,  thirty-one  years  old,  of  good 
habits  and  family  history,  was  seen  September  25,  Except 
for  an  attack  of.  "  inflammation  of  the  bowels  "  two  years  ago 
his  previous  health  has  been  excellent.  His  work  has  been 
hard,  and  for  about  two  months  past  he  has  been  consciously 
tired.  About  ten  days  ago  he  had  a  little  diarrhoea.  He  was 
then  all  right  for  several  days.  While  walking  in  the  street 
the  evening  of  September  15,  he  was  seized  with  severe  cramps 
in  the  abdomen,  not  localized,  recurring  through  the  night 
and  preventing  sleep;  no  diarrhoea  or  vomiting.  The  next 
morning  the  doctor  saw  him  in  bed  with  normal  pulse  and 
temperature ;  no  abdominal  tenderness ;  the  bowels  had  moved 
twice  normally  since  the  advent  of  the  pain.  The  next  day 
more  or  less  general  pain  was  still  present;  tenderness  over 
the  lower  abdomen,  more  marked  on  the  left  side,  was  noted; 
the  temperature  was  102°,  a.m.,  103°,  p.m.;  there  was  some 
diarrhoea.  Calomel  was  given  the  day  before,  opium  both 
days.  September  18  the  morning  temperature  was  104.5°, 
pulse  no,  pain  and  tenderness  were  more  marked,  and  slight 
distention  was  noted.  At  the  evening  visit  the  pain  had 
moved  to  the  epigastrium  and  subsequently  continued  high 
rather  than  low.  The  following  day  the  temperature  dropped 
to  100°,  pulse  to  90.  The  bowels  did  not  move  from  the 
1 8th  until  the  21st,  then  after  enema.  Again  on  the  24th 
there  was  a  large,  partly-formed  dejection,  and  much  gas 
passed  the  25th.  Vomited  twice  on  21st  after  barley  water; 
not  before  or  since.  Abdominal  distention  has  gradually  in- 
creased. 

The  mind  is  clear;  the  pulse  fairly  good;  tongue  slightly 
coated ;  decubitus  dorsal  with  legs  outstretched ;  moderate  pain 
and  tenderness  in  upper  abdomen,  not  sharply  localized;  chest 
negative;  abdomen  moderately  and  generally  distended,  duller 
in  the  flanks  and  hypogastrium  than  superiorly,  the  dull  areas 
changing  somewhat  with  changing  position.  Urine  and  rec- 
tal examination  negative.  No  tumor  or  localized  resistance. 
Blood  not  examined. 

1.  Common   causes   of   symmetrical   abdominal   distention.-* 

Tympanites,  obesity,  ascites,   tuberculous  peritonitis. 

2.  What   can   be   inferred   from   the   statement   "  decubitus 


INFECTIOUS  DISEASES.  77 

dorsal  with  legs  outstretched  "  ?     That  no  considerable 
psoas  spasm  is  present. 

Diagnosis:  The  sudden  onset  of  severe  abdominal  pain, 
with  fever,  rapid  pulse,  constipation,  abdominal  distention, 
slight  general  tenderness,  and  shifting  dulness  in  the  flanks, 
points  to  general  peritonitis  probably  due  to  appendicitis, 
possibly  to  cholecystitis  or  peptic  ulcer.  Calomel  aggravated 
the  lesions  and  opium  masked  the  symptoms.  Intestinal  ob- 
struction is  excluded  by  the  effect  of  cathartics. 

Prognosis:  Perhaps  one  case  in  five  recovers;  the  outlook 
depends  upon  the  virulence  of  the  infection  and  the  skill  and 
speed  of  the  surgeon. 

Treatment:  Laparotomy  and  drainage  is  the  obvious  indi- 
cation.    (For  fuller  discussion  see  Case  22.) 


78  CASE   HISTORIES    IN    MEDICINE. 

Case  24.  A  Lithuanian  teamster,  forty-eight,  entered  the 
hospital  April  22,  1904,  with  the  following  history:  Parents 
died  of  old  age.  He  uses  thirty-five  cents'  worth  of  tobacco 
a  week;  alcohol  occasionally.  He  has  always  been  well  until 
April  15,  when  he  went  to  work  feeling  all  right.  In  the  after- 
noon his  neck  began  to  pain  him,  he  was  chilly,  then  felt  hot, 
and  sweat  a  good  deal.  Later  his  neck  began  to  swell  and 
became  more  painful.  His  throat  was  sore,  dry,  and  painful 
on  swallowing.  Two  days  later  he  started  to  work,  but  had 
to  give  up  and  came  to  the  hospital. 

Physical  examination  showed  a  well-nourished  man  with 
slight  prostration.  Slight  conjunctivitis.  Tongue  protruded 
in  median  line.  Throat  dry,  red,  with  considerable  dirty 
secretion  on  the  walls  of  the  pharynx.  Slight  cyanosis  of  the 
face  and  finger  tips.  Neck  short,  thick,  and  reddened  at  the 
base  with  brawny  Induration.  Redness  and  Induration  ex- 
tend down  over  the  upper  part  of  the  chest.  Tenderness  and 
swelling  at  the  posterior  edge  of  the  sternocleidomastoid 
muscle  at  either  side. 

Inspection  shows  no  enlargement  of  the  veins  of  the  upper 
chest  or  of  the  arms.  Percussion  of  the  chest  shows  dulness 
over  manubrium,  extending  one  finger's  breadth  on  either 
side.  Lungs  are  apparently  normal.  Heart's  apex  in  fifth 
Interspace  nipple  line.  Right  border  at  right  sternal  edge. 
Sounds  distant,  no  murmurs  heard.  Pulse  120,  regular,  fair 
volume  and  tension.  Abdomen  full,  tympanitic,  not  tender. 
Liver  and  spleen  not  enlarged.  Knee-jerks  present,  no 
paralysis,  no  Kernig,  no  oedema,  no  general  glandular  en- 
largement. Blood  shows:  —  red  cells  5,001,800,  white  cells 
21,700,  haemoglobin  90%.  Differential  count  of  200  leuco- 
cytes shows:  —  polynuclears  78%,  lymphocytes  22%,  eosino- 
phlles  o.  Urine  normal,  amt.,  specific  gravity  1021,  albumin 
slight  trace,  chlorides  diminished.  Sediment:  numerous  hya- 
lin  and  fine  granular  casts,  with  occasional  cells  adherent. 
Occasional  free  mononuclear  cells,  rare  blood  corpuscle. 
Temperature  101.4°,  respiration  25. 

April.  24.  Delirium  for  past  two  days  requiring  restraint. 
Quieter  this  morning.  Throat  somewhat  cleaner,  less  cyano- 
sis and  tenderness  in  neck.  Otherwise  physical  examination 
unchanged. 


INFECTIOUS   DISEASES.  79 

May  I.  Temperature  has  ranged  from  99.5°  to  1014°  to- 
day. Pulse  from  120  to  lOO,  respiration  from  25  at  entrance 
to  35  to-day. 

May  2.  Tumor  at  side  of  neck  apparently  increasing  in 
size.  Some  oedema  over  the  neck,  and  the  small  veins  of 
that  region  more  prominent.  Bronchial  breathing  over  the 
right  infrascapular  region,  with  a  few  rales  just  below  the 
angle  of  the  scapula.  Some  cough  and  frothy  sputum. 
Laryngoscopic  report:  "  No  oedema  or  paralysis  of  recurrent 
laryngeal,  but  some  pressure  oedema  of  left  aryepiglottic 
fold." 

May  6.  Considerable  cough  and  expectoration.  Some 
abdominal  pain;  has  lost  considerable  weight.  Fever  lower; 
cervical  tumor  decreasing. 

1.  Causes  of  substernal  percussion  dulness?      Aneurism,  en- 

larged bronchial  glands  (tuberculosis,  pseudoleucaemia, 
sepsis,  cancer,  sarcoma),  tumors  of  the  thyroid  or  thy- 
mus gland,  mediastinal  abscess. 

2.  Significance  of  the  lack  of  eosinophils  here?     Eosino- 

philes  may  disappear  in  a  severe  type  of  any  infection 
which  causes  leucocytosis,  occasionally  in  toxic  condi- 
tions associated  with  leucocytosis,  and  in  some  severe 
anaemias.  Their  reappearance  is  always  a  favorable 
sign. 

3.  How  is  the  patient's  delirium  to  be  accounted  for?     Any 

severe  infection  may  produce  delirium,  though  menin- 
gitis and  pneumonia  most  often  do  so.  The  particular 
infection  here  present  is  also  especially  prone  to  delirium. 

4.  Of  what  diagnostic  value  is  the  fact  that  Kernig's  sign  is 

absent?  Kernig's  sign  is  usually  present  in  meningitis 
of  any  type.     Its  absence  tends  to  exclude  meningitis. 

5.  What  further  facts  are  needed  for  diagnosis  in  this  case  ? 

The  sputum  should  be  examined  for  tubercle  bacilli. 
No  other  data  are  essential,  but  a  Widal  reaction  might 
help  to  exclude  typhoid,  and  a  spinal  puncture  to  exclude 
meningitis. 

Diagnosis:  The  physical  signs  of  disease  are  chiefly  in  the 
neck  and  upper  thoracic  region.  Tuberculosis  of  the  lung, 
meninges,  and  cervical  glands  would  account  for  some  of  the 
signs,  but  would  not  be  likely  to  produce  so  much  pain  and 
local  oedema.     The  sputa  are  negative  for   tubercle   bacilli 


8o  CASE   HISTORIES   IN   MEDICINE. 

on  repeated  examination.  Venous  thrombosis  would  not 
explain  the  inflammatory  reaction  in  the  neck  and  would 
cause  more  oedema  and  more  enlargement  of  the  superficial 
veins.  The  same  evidence  is  valid  against  mediastinal  new 
growth  or  abscess.  Deep-seated  inflammation  in  the  neck 
(with  or  without  pus)  is  the  most  defensible  diagnosis, — 
Ludwig's  angina.     The  Widal  reaction  is  negative. 

Prognosis:  The  majority  of  cases  die  unless  operated 
upon,  and  even  with  this  assistance  the  outlook  is  grave. 
Convalescence  is  always  tardy  and  painful.  There  is,  how- 
ever, no  special  tendency  to  relapse,  if  the  patient  once 
conquers  his  infection.  In  this  case,  defervescence  and  im- 
provement of  all  symptoms  went  on  slowly  but  steadily 
after  May  6,  and  in  a  few  weeks  he  was  well  —  substantially 
without  interference  other  than  good  nursing. 

Treatment:  Surgical  interference  should  be  called  for  as 
soon  as  the  diagnosis  is  made.  The  surgeon  may  be  unable 
to  locate  any  considerable  focus  of  pus,  but  even  an  incision 
into  inflamed  and  congested  areas  seems  to  be  of  benefit, 
as  with  many  cases  of  peritonsillar  abscess.  Before  and 
after  operation  relief  of  pain  is  to  be  obtained  chiefly  by 
poulticing  or  in  extreme  cases  by  morphia.  The  patient  gets 
some  relief  from  sucking  small  pieces  of  ice  and  from  the 
swallowing  of  very  cold  foods. 


INFECTIOUS   DISEASES.  8 1 

Case  25.  A  negress  of  sixty-seven  has  had  "  falling  of  the 
womb  "  for  forty  years.  To  hold  it  up  she  stuffs  a  wad  of 
cotton  into  the  vagina  and  ties  a  tight  bandage  round  the 
lower  part  of  the  abdomen.  Some  years  ago  a  lump  grew 
in  her  belly,  —  "  sore  as  a  boil."  One  night  she  heard  a 
click,  felt  something  give  way,  and  "  it  all  ran  out  the  front 
passage,"  after  which  she  felt  all  right.  Eight  months  ago 
she  noticed  another  lump  in  her  belly,  not  tender,  but  some- 
times "  it  kicks  just  like  a  baby." 

Five  days  ago  she  "  felt  pretty  smart,"  but  had  had  no 
dejection  for  two  days.  Four  days  ago  swelling  of  the  belly, 
tenderness  in  the  left  groin,  and  vomiting  began.  Three  days 
ago  she  had  a  small,  hard  dejection  and  ceased  vomiting, 
but  since  then  "  the  lump  in  her  belly  has  been  moving 
round  and  making  a  noise."  Pain,  distention,  and  constipa- 
tion have  continued. 

Examination:  Does  not  seem  much  sick.  Temperature 
100°,  pulse  100,  respiration  32.  Chest  negative.  Belly 
much  distended,  tympanitic,  and  somewhat  tender,  especially 
in  the  left  iliac  fossa,  where  there  is  dulness  and  a  rounded 
mass  the  size  of  an  orange  is  felt.  Pressure  over  this  mass 
causes  the  cervix  uteri  to  move  down.  No  thorough  pelvic 
examination  is  possible  on  account  of  tenderness. 

1.  What  was  the  probable  cause  of  the  symptoms  described 

in  lines  5-7  ?     Salpingitis  or  pelvic  peritonitis. 

2.  By  what  means  can  we  secure  abdominal  relaxation  when 

deep  palpation  is  important?     A  warm  bath  or,  if  the 
bath  is  insufficient,  an  anaesthetic. 

3.  What  light  might  be  thrown  on  this  case  by  examination 

of  the  blood  ?     If  leucocytosis  is  absent,  suppuration  is 
unlikely. 

4.  Should   you   recommend  operation  in   this  case  ?     What 

would  influence  your  decision  ?     (See  below  —  Treat- 
ment.) 

Diagnosis:  The  history  is  of  salpingitis  some  years  ago,  — 
of  a  painless  lump  in  the  belly  for  eight  months,  and  of  five 
days'  acute  symptoms.  The  acute  symptoms  are  constipa- 
tion, vomiting,  painful,  swollen,  and  tender  belly,  with  bor- 
borygmi  and  slight  fever.  A  mass  apparently  connected  with 
the  uterus  is  also  felt.     In  a  negress  any  pelvic  disturbance 


82  CASE   HISTORIES   IN   MEDICINE. 

should  suggest  fibroid,  especially  if  there  is  a  palpable  tumor 
connected  with  the  uterus.  How  can  a  fibroid  produce  acute 
symptoms  ?  By  suppuration,  twisting  of  a  pedunculated  por- 
tion, or  both.  The  methods  of  holding  up  the  uterus  de- 
scribed in  paragraph  one  would  certainly  favor  the  occurrence 
of  pelvic  suppuration,  but  it  is  hard  to  say  whether  they  are 
connected  with  the  symptoms  in  this  case.  Further  diag- 
nosis is  impossible  with  the  data  given. 

Prognosis:  That  in  the  great  majority  of  these  suppura- 
tions and  degenerations  in  uterine  fibroids  recovery  follows  is 
shown  from  the  numbers  of  adhesions  and  contracted  scar 
formations  which  are  to  be  seen  on  operation  or  post  mortem 
in  most  long-standing  cases.  Aside  from  the  general  knowl- 
edge thus  obtained,  one  can  judge  of  the  severity  of  each 
individual  case  only  by  the  degree  of  constitutional  reaction 
such  as  fever,  tachycardia,  chill,  sweating,  vomiting,  leucocy- 
tosis,  local  pain,  and  muscular  spasm.  The  degree  of  favor- 
able response  to  simple  methods  of  treatment  of  course 
influences  our  judgment  regarding  the  outlook. 

Treatment:  Rest  in  bed  and  hot  poulticing  will  relieve 
many  cases  without  any  further  interference.  Free  evacua- 
tion of  the  bowels  should  be  secured,  and  the  patient  fed  as 
in  any  other  infectious  fever,  i.e.,  according  to  the  digestive 
power,  but  without  the  omission  of  any  one  class  of  foods. 
If  fever,  pain,  spasm,  and  leucocytosis  persist  or  increase 
despite  these  simple  measures,  laparotomy  and  probably 
hysterectomy  must  be  performed. 


INFECTIOUS   DISEASES.  83 

Case  26.  The  patient  is  a  man  of  thirty-five,  who  has  had 
fever  and  cough  for  two  weeks.  At  the  onset  he  had  much 
pain  in  the  front  and  right  side  of  chest,  near  attachment  of 
diaphragm.  Had  a  chill  on  two  successive  days  and  on  the 
fourth  day.  No  dyspnoea;  no  sputa  till  sixth  day,  when  a 
scanty,  mucopurulent  spit  began  and  has  steadily  increased 
in  amount  and  grown  more  purulent  since.  The  fever  has 
ranged  from  ioi°  to  104°,  and  at  times  there  has  been  a  good 
deal  of  sweating  and  slight  delirium.  Has  taken  liquids 
fairly  well.  The  bowels  are  rather  loose,  as  they  have  been 
off  and  on  for  several  years.     No  pain  anywhere  now. 

The  man  is  sallow,  dull,  and  listless;  tongue  clean.  Poorly 
nourished.  Over  lower  half  of  right  chest  marked  dulness, 
with  distant  bronchial  respiration  and  increased  whisper; 
voice  sounds  nasal,  especially  near  angle  of  scapula.  Frem- 
itus nearly  absent.  Over  upper  half  of  lung  medium  moist 
rales  were  heard  on  the  first  and  third  days  and  none  on  the 
second.  Viscera  otherwise  negative,  except  slight  tenderness 
and  fulness  in  the  abdomen. 

Sputa  examined  twice  for  bacilli;  none  found. 

Urine  high-colored,  acid  1027,  trace  of  albumin,  no  sugar. 

Sediment:  Abundant  urates,  leucocytes,  and  squamous 
cells.     Few  hyalin  and  coarse  granular  casts. 

Blood:   Red  4,200,000;  white,  26,000;  Hg  43%. 

1.  What  points  are  against  the  diagnosis  of  typhoid  fever 

(with  complications)  here  ?  Typhoid  even  with  lung 
complications  usually  runs  its  course  without  leucocy- 
tosis.  Splenic  tumor  and  rose  spots  are  apparently 
absent.  The  Widal  reaction  should  be  tried.  If  it  is 
absent,  typhoid  is  unlikely. 

2.  Significance  of  nasal  voice  sounds?     This  is  "  egophony  " 

and  occurs  oftenest  in  pleural  effusion  —  sometimes  in 
solidification  of  the  lung  from  any  cause. 

3.  What  further  examination  is  essential  in  this  case  ?     Punc- 

ture of  the  chest. 

4.  Comment  on  the  urinary  sediment.     In  most  fevers  one 

sees  such  sediment;  it  has  no  diagnostic  value. 

5.  Common  causes  of  leucocytosis  ?     Infections,  local  or  gen- 

eral, due  to  cocci  (strepto-,  staphylo-,  pneumo-,  gono- 
meningococci),  scarlet  fever  and  diphtheria,  violent 
muscular  exertion,  some  toxaemias,  e.g.,  uraemia  and 
gas  poisoning,  and  any  acyte  organic  brain  lesion. 


84  CASE   HISTORIES   IN   MEDICINE. 

Diagnosis:  Phthisis,  unresolved  pneumonia,  abscess  of  the 
lung,  empyema,  or  subdiaphragmatic  abscess  rupturing  into 
the  lung,  are  the  diagnoses  most  deserving  consideration. 
The  two  negative  sputum  examinations  make  phthisis  un- 
likely, but  do  not  exclude  it.  Unresolved  pneumonia  does 
not  produce  profuse  purulent  sputa.  The  signs  and  symp- 
toms of  the  other  lesions  above  mentioned  may  be  identical. 
Abscess  of  the  lung  is  rare,  and  a  definite  cause  (such  as  the 
inhaling  of  food  or  foul  material)  is  usually  to  be  found.  The 
same  is  true  of  subdiaphragmatic  abscess.  Empyema  not 
uncommonly  breaks  through  the  lung.  Hence  statistical 
grounds  should  incline  us  towards  this  diagnosis.  Explor- 
atory puncture  is  the  next  and  most  important  means  of 
clearing  up  the  diagnosis. 

Prognosis:  Under  proper  treatment,  that  is,  under  early 
and  efficient  surgical  drainage,  the  vast  majority  of  cases  of 
empyema  will  thoroughly  and  permanently  recover,  though 
the  process  is  apt  to  consume  a  number  of  months  before  its 
termination  is  reached. 

Exception  should  be  made  of  the  rather  rare  cases  of 
tuberculous  empyema,  which  may  persist  unhealed  for  many 
years,  despite  operation,  and  finally  wear  the  patient  out 
with  sepsis  and  amyloid  degeneration  of  the  parenchymatous 
organs. 

For  the  vast  majority  of  cases,  however,  which  are  due  to 
the  pneumococcus,  the  favorable  prognosis  stated  holds  good. 

Treatment:  Every  case  should  be  operated  on  as  soon  as 
the  diagnosis  is  made.  There  is  no  possible  ground  for 
delaying  operation  or  for  trying  any  other  method  of  treat- 
ment. Experience  has  abundantly  proved  that  neither  simple 
tapping,  with  or  without  the  injection  of  antiseptic  mixtures, 
nor  any  form  of  internal  medication  can  be  counted  upon  to 
check  the  infection.  We  should  delay  merely  until  we  can 
establish  as  accurately  as  possible  the  position  of  the  suppu- 
rative focus.  Sometimes  even  this  is  impossible  until  a  good- 
sized  surgical  opening,  involving  the  excision  of  one  or  more 
ribs,  has  been  made. 

While  the  above  statement  can  be  made  without  any 
modification  so  long  as  we  keep  clear  the  traditional  defini- 


INFECTIOUS   DISEASES.  85 

tion  of  empyema,  it  must  be  remembered  that  if  we  chance 
to  perform  paracentesis  in  almost  any  case  of  pneumonia  we 
may  find  a  few  cubic  centimeters  of  clear  or  turbid  fluid 
containing  a  sediment  made  up  of  polynuclear  cells  and  bac- 
teria, this  is  not  empyema,  although  certain  rash  or  academ- 
ically minded  persons  may  be  disposed  to  treat  it  as  such. 
It  needs  no  interference  and  is  absorbed  along  with  the 
pneumonic  exudate. 

When,  as  in  the  present  case,  an  empyema  has  ruptured 
into  the  bronchus,  and  is  draining  by  mouth,  the  question 
as  regards  the  advisability  of  operation  depends  upon  making 
up  one's  mind  whether  or  not  the  drainage  is  really  efficient. 
Under  efficient  drainage  the  patient's  temperature  and  pulse 
should  steadily  approach  normal,  the  leucocytes  should 
diminish,  and  the  general  condition  improve.  The  amount 
of  sputum,  after  continuing  profuse  for  a  considerable  period, 
should  very  gradually  diminish.  The  physical  signs  should 
progressively  improve,  or  at  any  rate  get  no  worse.  Under 
these  conditions  operation  may  be  unnecessary.  Otherwise 
it  is  demanded. 


86  CASE   HISTORIES    IN   MEDICINE. 

Case  27.  A  merchant,  aged  thirty-five,  is  seen  March  30. 
Has  never  been  very  rugged.  Last  summer  had  a  cough 
which  persisted  until  he  went  to  the  mountains.  Lately  has 
felt  rather  better  than  usual.  On  the  evening  of  March  28, 
attended  an  elaborate  dinner.  Shortly  after  returning  home, 
he  had  a  chill  and  began  to  vomit,  lobster  and  mushrooms 
being  noted  in  the  vomitus.  On  the  morning  of  the  29th  he 
complained  of  nausea  and  violent  headache.  Temperature 
101°,  pulse  96.  Toward  noon  he  began  to  grow  stupid  and 
within  an  hour  could  not  be  roused.  The  respiration  became 
rhythmical  with  occasional  intervals  of  apnoea  lasting  twenty- 
five  seconds.  The  pulse  also  was  rhythmical,  varying  from 
38  to  108  as  extreme  limits,  the  lower  rate  corresponding  to 
the  periods  of  apnoea.  On  the  morning  of  the  30th  he  had 
regained  consciousness  but  was  still  dull.  Headache  much 
better.  Temperature  normal,  pulse  and  respiration  showed 
a  hardly  noticeable  rhythm.  Vomiting  had  not  occurred 
since  eleven  o'clock  the  preceding  day.  He  was  still  dull, 
but  could  be  roused  to  take  interest  in  his  surroundings.  Is 
constantly  tossing  about  the  bed.  At  five  o'clock  in  the 
afternoon,  his  physician  noticed  that  he  was  absolutely  deaf. 
Examination  of  ears  negative.  He  replied  intelligently  but 
slowly  to  written  questions,  and  appeared  to  have  some 
difficulty  in  seeing  them.  For  the  past  twenty-four  hours 
he  has  required  catheterization.  Temperature  98°,  pulse  72, 
respiration  24. 

Physical  examination  shows  a  pale  but  fairly  well-nourished 
man.  Pupils  contracted  and  unresponsive  to  light.  Head 
moves  freely  except  forward,  in  which  direction  motion  seems 
slightly  restricted.  Examination  of  chest  and  abdomen  nega- 
tive, except  for  a  slight  systolic  murmur  over  the  pulmonic 
area.  Knee-jerks  lively,  but  equal.  No  Babinski,  no  ankle- 
clonus.  Patient  apparently  has  full  control  of  all  his  muscles. 
White  cells  16,000.  Urine  high-colored,  specific  gravity  1024, 
acid,  very  slight  trace  albumin,  few  hyalin  and  fine  granu- 
lar casts,  no  sugar.  Amount  in  past  twenty-four  hours,  32 
ounces. 

I.    What  is  the  significance  of  rhythmic  changes  in  pulse  and 
respiration  ?     Cheyne-Stokes  breathing. 


INFECTIOUS   DISEASES.  87 

2.  How  do  you  explain  the  cough  of  the  previous  summer? 

It   may  have  been  due   to   tuberculosis   or  simply   to 
bronchitis. 

3.  What  was  the  use  of  asking  him  to  answer  written  ques- 

tions ?     To  test  his  cerebration. 

Diagnosis:  Ptomaine  poisoning,  uraemia,  and  meningitis 
should  be  considered.  The  first  two  do  not  stiffen  the  neck 
or  produce  deafness.  The  urine  is  not  characteristic  of  any 
type  of  nephritis.  The  blood  and  urine  are  consistent  with 
any  of  the  diagnoses  considered.  In  favor  of  meningitis  is 
the  predominance  of  cerebral  symptoms  (coma,  Cheyne- 
Stokes  breathing,  deafness,  stiffened  neck,  headache)  in  a 
febrile  disease  of  acute  onset.  Death  occurred  in  three  days 
and  epidemic  meningitis  was  found  at  autopsy. 

Prognosis :  Since  the  discovery  of  Flexner's  anti-meningitis 
serum,  the  prognosis  of  epidemic  cerebrospinal  meningitis -is 
good  in  about  75%  of  cases,  instead  of  25%  as  was  previ- 
ously the  case.  Even  a  larger  proportion  of  patients  can  be 
saved  if  the  diagnosis  is  made  early,  and  the  treatment  is 
vigorous  and  prompt.  Other  things  being  equal,  the  infec- 
tions are  more  fatal  in  adults  than  in  children.  If  recovery 
occurs  it  is  usually  complete  within  a  month  or  two,  and  there 
is  no  danger  of  relapse.  Occasionally,  however,  a  case  may 
drag  on  into  a  chronic  form  with  great  emaciation  and  irregu- 
lar waves  of  fever  protracted  over  a  number  of  months,  and 
finally  ending  either  in  death  or  in  recovery.  Since  the  use 
of  Flexner's  serum  these  chronic  cases  have  been  much  less 
frequent  and  more  favorable  in  outcome. 

This  serum  has  also  reduced  very  materially  the  number 
of  post-febrile  complications  such  as  deafness,  blindness,  or 
mental  impairment,  though  there  are  still  a  good  many  cases 
of  deafness  despite  all  that  the  serum  can  do. 

Treatment:  As  soon  as  the  diagnosis  is  made,  Flexner's 
serum  should  be  injected  daily,  the  quantity  introduced  being 
the  same  as  withdrawn  by  the  immediately  preceding  lumbar 
puncture.  If  this  treatment  is  faithfully  carried  out,  nothing 
else  except  good  nursing  is  required.  The  patient  can  be  fed 
substantially  according  to  the  method  given  under  the  treat- 
ment of  typhoid  fever.     Analgesics,  hypnotics,  and  laxatives 


88  CASE   HISTORIES   IN   MEDICINE. 

are  rarely  required.  The  bowels  may  be  moved  by  enema 
every  second  day  if  they  do  not  act  spontaneously.  Great 
care  should  be  taken  to  prevent  bed-sores,  the  methods  used 
being  essentially  those  already  detailed  on  page  40. 


INFECTIOUS   DISEASES.  89 

Case  28.  A  boy  of  fourteen,  a  new  inmate  of  a  reform 
school,  was  seized  February  i8,  1903,  with  headache,  backache, 
and  fever.  His  appetite  became  poor  but  he  managed  to  go 
to  his  meals  that  day.  Next  day  a  red  papular  rash  appeared, 
scattered  over  the  entire  body.  On  the  third  day  some  of  the 
lesions  began  to  be  pustular,  and  when  he  was  seen  by  the 
writer  on  the  fourth  day  the  great  majority  was  distinctly 
pustular  and  had  a  hard,  shotty  feel  under  the  skin.  Some 
were  drying  up  and  covered  with  dark-red  crusts.  The  fever 
was  continued,  ranging  between  100°  and  102°.  The  boy  felt 
decidedly  sick,  and  could  take  only  liquids  without  nausea. 
Slight  headache  and  general  muscular  soreness  persisted. 

The  rash  was  nowhere  confluent,  and  the  skin  between  the 
lesions  was  normal.  The  internal  viscera  were  apparently 
normal,  as  was  the  blood.  The  urine  showed  the  character- 
istics usual  in  fevers. 

It  was  subsequently  learned  that  he  had  taken  some  cough 
medicine  for  the  ten  days  ending  one  week  before  the  present 
illness  began.  The  nature  of  this  medicine  could  not  be 
learned.  There  were  no  other  cases  like  this  in  the  reform 
school. 

I.  Commonest  causes  of  generalized  pustular  eruptions? 
Acne  and  furunculosis,  drug-poisoning,  chicken-pox, 
small-pox.  Less  common  are  pustular  eczema  and 
impetigo  contagiosa. 

Diagnosis :  The  presence  of  fever  and  constitutional  symp- 
toms makes  all  of  the  above  affections  unlikely,  except  vari- 
cella and  variola.  Acne  and  furunculosis  do  not  appear  so 
rapidly,  and  this  is  equally  true  of  the  eczema  and  impetigo. 
Our  diagnosis  practically  is  between  varicella  and  variola. 
The  constitutional  signs  (pain,  fever,  and  digestive  disturb- 
ance) and  the  shotty  feel  of  the  lesions  point  rather  to  variola. 
Decidedly,  and  on  the  whole  definitively,  against  variola  is 
the  rapidity  with  which  the  lesions  reached  and  passed  their 
maturity.  It  is  almost  unheard  of  that  any  part  of  a  small-pox 
eruption  should  have  passed  through  the  pustular  stage  and 
be  drying  up  by  the  fourth  day.  The  diagnosis  of  exan- 
thematous  infection  will  never  be  satisfactory  as  long  as  it 


90  CASE   HISTORIES   IN   MEDICINE. 

has  to  rest  on  the  characteristics  of  the  exanthemata,  but  we 
have  at  present  no  more  reliable  clinical  test. 

The  fact  that  there  were  no  other  cases  in  the  school  was 
of  no  importance  in  diagnosis,  for  the  boy  had  but  recently 
entered  it.  Drug  eruptions  are  always  to  be  remembered  in 
such  cases,  but  it  seems  very  unlikely  that  any  such  eruption 
could  produce  so  much  pain,  fever,  and  digestive  disturbance. 

Prognosis :  Except  for  the  very  rare  cases  of  streptococcus 
infection  with  resulting  erysipelas  or  arthritis,  there  are  no 
serious  complications  of  chicken-pox  beyond  the  nephritis 
which  in  isolated  instances  has  been  known  to  occur.  The 
vast  majority  of  cases  recover  without  any  complication  or 
any  serious  symptoms.  A  week  or  two  usually  makes  an  end 
of  all  manifestations  of  the  disease. 

Treatment :  Nothing  more  than  isolation  is  necessary.  The 
vast  majority  of  cases  are  not  really  sick  and  require  nothing 
more  than  a  slight  simplification  of  diet. 


INFECTIOUS    DISEASES.  9 1 

Case  29.  J.  B.,  male,  aged  thirty- two  (occupation,  cook), 
came  to  the  out-patient  department  of  the  hospital  January 
6,  1899.  His  family  history  was  negative  and  previous  his- 
tory good.  He  denied  any  syphilitic  infection,  but  admitted 
having  had  a  urethritis  some  years  previously.  He  had  never 
had  an  attack  similar  in  character  to  the  present.  His  ill- 
ness dates  from  December  30,  1898,  eight  days  before  he  ap- 
plied for  relief  at  the  hospital.  The  first  symptoms  seemed 
to  have  come  on  rather  suddenly  with  a  rigor  of  marked 
severity,  followed  by  fever  and,  later,  by  profuse  sweating. 
Almost  immediately  afterward  he  was  seized  with  intense 
muscular  pains,  extending  over  the  trunk  and  limbs;  these 
pains  were  agonizing  in  character,  increased  on  the  slightest 
exertion,  and  had  been  present,  with  varying  degree's  of 
severity,  until  his  admission.  They  prevented  him  from 
sleeping,  and  were  spoken  of  by  the  patient  as  being  not  un- 
like rheumatism,  i.e.,  dull  and  aching,  while  he  was  in  the  re- 
cumbent posture,  becoming  intensely  lancinating  as  soon  as 
the  slightest  exercise  was  attempted.  His  appetite,  which 
had  previously  been  of  the  best,  was  absolutely  lost  and  he 
had  eaten  nothing  for  three  days.  With  the  exception  of 
some  little  frequency  of  micturition  and  a  slight  cough  with 
expectoration,  there  was  nothing  else  of  importance  in  the 
history  of  the  illness. 

Examination:  The  patient  was  rather  a  large,  well-formed 
man,  the  mucous  membranes  of  good  color,  tongue  moist,  and 
with  a  slight  white  fur.  The  eyes  were  markedly  injected, 
the  eyelids  slightly  but  distinctly  oedematous,  and  an  eryth- 
ematous area  above  the  swelling.  Negative  results  were  ob- 
tained everywhere  on  auscultation  and  percussion,  except  at 
the  bases  of  both  lungs  behind,  where  a  few  moist  rales  were 
made  out.  The  heart  sounds  were  quite  clear.  The  liver 
and  spleen  were  not  palpable;  the  abdomen  was  soft  and 
natural  in  appearance,  negative  results  being  obtained  on  pal- 
pation. No  rose  spots  were  seen.  There  was  no  superficial 
glandular  enlargement.  Pulse  was  100,  respiration  24  to  the 
minute.  The  temperature  ranged  in  the  vicinity  of  103°  for 
three  weeks  and  then  gradually  subsided.  The  urine  was 
normal  in  color,  acid,  specific  gravity  1026.     Microscopically, 


92  CASE   HISTORIES   IN   MEDICINE. 

it  showed  pus-corpuscles  in  considerable  quantity,  epithelial 
cells,  and  a  few  mucous  casts. 

1.  What  important  information  might  be  gained  by  testing 

the  knee-jerks  in  this  case  ?  Neuritis  —  one  of  the  diag- 
noses to  be  considered  in  this  case  —  would  be  suggested 
if  the  knee-jerks  were  diminished  or  absent. 

2.  Commonest  causes  (a)  of  absent  knee-jerk  ?  {h)  of  increased 

knee-jerk?  (a)  Neuritis,  tabes,  anterior  poliomyelitis. 
{h)  Brain  haemorrhage  or  other  organic  brain  lesion  (focal 
or  diffuse) ,  spastic  paraplegia,  pressure  myelitis,  chronic 
arthritis. 

3.  What  infectious  diseases  cause  severe  pains  in  the  trunk 

and  limbs  ?  Grippe,  tonsilitis,  variola,  dengue,  trichini- 
asis,  yellow  fever.  Milder  pains  accompany  some  cases 
of  typhoid,  sepsis,  pneumonia,  or  any  other  infection. 

4.  What  further  examinations  would  throw  light  upon  your 

preliminary  diagnosis  here?  Blood  examination  and 
tests  of  the  deep  reflexes. 

Diagnosis:  Blood  examination  showed  a  leucocytosis. 
This  suggested  a  differential  count  which  revealed  a  very 
marked  eosinophilia.  A  bit  of  the  biceps  muscle  was  then 
excised  and  trichinae  were  demonstrated  in  it  by  histological 
examination.  If  blood  examination  is  included  in  our  inves- 
tigation of  such  a  case,  diagnosis  (in  temperate  climates)  is 
usually  very  easy  as  there  is  no  other  chronic  febrile  disease 
with  eosinophilia  and  severe  muscular  pains.  In  the  tropics 
other  fevers  complicated  by  the  presence  of  intestinal  para- 
sites may  be  hard  to  distinguish  from  trichiniasis  unless 
trichinae  are  found  in  the  muscles.  In  any  climate  many 
cases  closely  simulate  typhoid  and  without  blood  examina- 
tion are  sure  to  be  mistaken  for  it.  Others  pass  as  "  muscu- 
lar rheumatism." 

Prognosis :  The  outlook  depends  upon  the  number  of  trich- 
inae which  have  been  taken  in  with  the  infected  meat.- 
The  mortality'  varies  greatly  in  different  epidemics.  Some- 
times nearly  a  third  of  all  those  affected  die.  As  a  rule,  how- 
ever, the  outlook  is  much  more  favorable  and  in  some  epi- 
demics only  one  or  two  per  cent  of  the  cases  are  fatal.  The 
duration  of  an  attack  is  usually  comparable  with  that  of 
typhoid  fever  though  the  convalescence  is  sometimes  some- 
what slower.     Relapse  occasionally  occurs.     I  have  followed 


INFECTIOUS   DISEASES.  93 

one  such  case  with  great  interest.     Children  are  less  seri- 
ously affected  than  adults  as  a  rule. 

Treatment:  No  drugs  or  other  therapeutic  measures  yet 
suggested  have  any  obvious  effect  upon  the  course  of  the 
disease.  Most  patients  suffer  very  little  as  long  as  they  lie 
quiet  in  bed.  After  the  initial  gastro-enteric  disturbances, 
which  may  be  very  slight,  there  is  usually  no  trouble  with 
digestion  and  the  symptoms  are  those  of  any  infectious  fever. 
Practically  all  that  has  been  said  under  the  heading  of  treat- 
ment in  typhoid  fever  may  therefore  be  applied  to  the  man- 
agement of  trichiniasis.  Hot  applications,  aspirin  or  ace- 
tanilid,  rarely  morphin,  may  be  employed  for  the  control  of 
pain,  though  as  previously  mentioned  this  is  rarely  severe. 
The  most  important  element  in  treatment  is  the  education 
of  the  patient,  his  family,  friends,  and  neighbors  regarding 
the  dangers  of  eating  raw  or  imperfectly  cooked  pork  in  any 
form. 


94  CASE   HISTORIES   IN   MEDICINE. 

Case  30.  July  20,  1905,  a  girl  of  sixteen,  previously 
healthy,  was  attacked  in  the  morning  by  pain  in  the  sternum 
with  a  sense  of  pressure.  Later  the  pain  extended  round  the 
chest  and  became  severe  on  any  movement  of  the  intercostal 
muscles  —  so  that  breathing  was  painful  and  shallow.  She 
felt  feverish  and  nauseated,  and  in  the  evening  her  temper- 
ature rose  to  101°.  She  slept  fairly  well  and  next  day  her 
fever  was  gone  and  she  was  almost  well;  walked,  drove,  and 
ate  her  meals  with  good  appetite.  On  the  third  day  the  pain 
and  fever  returned  and  both  were  worse  than  before ;  the 
pain  extended  round  both  sides  of  the  chest,  from  the  armpit 
to  the  bottom  of  the  ribs,  and  also  into  both  shoulders.  In 
the  evening  the  temperature  was  103°.  Next  day  she  re- 
mained in  bed  feeling  greatly  improved,  but  still  somewhat 
sore  and  achey. 

On  the  fifth  day  the  pain  came  three  or  four  hours  earlier 
than  in  the  previous  attack,  and  was  agonizing  in  character. 
The  temperature  reached  104°  in  the  evening. 

There  was  no  chill,  no  sweating,  and  no  cough  at  any  time. 
Visceral  examination  was  negative  —  also  the  urine.  The 
blood  was  not  examined.  Calomel  was  given  on  the  fourth 
day,   without  relief. 

1 .  (a)  Causes  of  severe  thoracic  pain  ?     (b)  Of  mild  thor- 

acic pain  ?  (a)  Pleurisy  (pneumonic,  tuberculous,  or 
"  simple "),  angina  pectoris  (organic  or  functional), 
intercostal  neuralgia,  muscular  pain  ("  pleurodynia  "), 
spondylitis  (nerve-root  pains),  trichiniasis,  aneurism. 
(h)   Infectious  diseases,  fatigue. 

2.  By  what  additional  data  could  diagnosis  be  made  easier 

here  ?  A  careful  history  with  special  reference  to  a  pos- 
sible source  of  infection;  a  thorough  examination  of  the 
blood  and  of  the  spleen. 

Diagnosis:  Paroxysms  of  fever  recurring  every  second  day 
with  complete  apyrexia  on  the  intervening  days,  almost  never 
occurs  except  in  malaria.  Pyogenic  infections  (including 
advanced  phthisis)  may,  in  rare  cases,  produce  such  a  fever 
curve,  but  in  these  conditions  the  patient  is  never  as  well  on 
the  intervening  days  as  this  patient  was,  and  usually  shows 
well-marked  local  lesions  of  some  kind.  The  pains  of  this 
case  are  very  unusual  for  malaria  but  not  unknown,  and  it 


INFECTIOUS   DISEASES.  95 

is  a  safe  rule  to  assume,  until  it  is  proved  to  the  contrary, 
that  any  symptoms  that  recur  every  forty-eight  hours,  with 
fever,  and  disappear  completely  on  the  intervening  days,  leav- 
ing no  physical  signs  of  disease,  are  due  to  malaria.  The 
blood  was  not  examined  in  this  case  until  after  quinin  had 
been  given  with  complete  and  permanent  relief  of  all  symp- 
toms. After  this  no  parasites  were  found  in  the  blood.  Ab- 
dominal pain  is  not  infrequently  the  only  striking  symptom 
of  malaria,  but  thoracic  pain  is  rare. 

Prognosis:  I  have  yet  to  be  convinced  that  there  are  any 
cases  of  tertian  malaria  accurately  diagnosed  as  such  by 
good  examination,  which  resist  treatment  by  quinin.  Diffi- 
culties occur,  I  believe,  only  in  connection  with  the  other 
types  of  the  disease,  and  chiefly  the  aestivo-autumnal  form 
which  occasionally  resembles  the  tertian  in  its  symptoms. 
Here  I  shall  consider  only  the  true  tertian.  Under  prompt 
and  efficient  treatment  the  active  symptoms  of  the  disease 
should  be  over  within  four  days,  usually  within  forty-eight 
hours.  Some  weakness  and  anaemia  may  of  course  remain  if 
the  infection  has  been  allowed  previously  to  go  on  for  some 
weeks  unchecked.  Very  rarely  acutie  nephritis  may  darken 
the  otherwise  wholly  favorable  outlook. 

Treatment :  In  my  experience  it  is  wholly  immaterial  what 
form  of  quinin  is  given  or  what  the  relation  between  the 
administration  of  the  drug  and  the  progress  of  the  symp- 
toms, provided  always  that  the  quinin  actually  gets  into  the 
blood.  One  can  kill  the  organism  by  administering  quinin 
before  a  chill,  after  a  chill,  in  hourly  doses,  or  at  eight-hour 
intervals.  But  whatever  way  we  give  it,  we  must  be  sure 
that  it  is  actually  dissolved  and  absorbed.  It  is  above  all 
important  to  avoid  the  ancient  and  dessicated  pills  some- 
times brought  down  by  the  apothecary  from  an  upper  shelf, 
for  these  are  capable  of  passing  through  the  intestinal  tube 
without  being  dissolved  or  absorbed  at  all.  To  insure  the 
absorption  of  the  drug  one  should  administer  it  either  in 
compressed  uncoated  tablets  or  in  capsule.  The  sulphate 
of  quinin,  though  somewhat  less  effective  than  other  salts, 
is  so  much  cheaper  that  it  may  well  be  employed  in  the  great 
majority  of  cases. 


96  CASE  HISTORIES   IN   MEDICINE. 

Thirty  grains'  should  be  administered  in  the  first  twenty- 
four  hours,  after  the  diagnosis  is  established,  lo  grains  in  the 
next  twenty-four  hours,  lo  in  the  third  twenty-four  hours, 
and  thereafter  2  grains  three  times  a  day  until  a  week  has 
elapsed.  Experience  has  shown  that  it  is  well  to  give  a  some- 
what larger  dose,  say  10  grains  a  day,  upon  the  seventh, 
fourteenth,  twenty-first,  and  twenty-eighth  days  after  the 
last  chill. 

In  the  rare  cases  in  which  there  is  an  idiosyncrasy  against 
the  drug,  and  in  cases  of  middle-ear  disease  in  which  the  pain 
due  to  congestion  of  the  middle  ear  from  the  quinin  is  very 
severe,  one  may  use  euquinin,  and  if  that  fails  methylene- 
blue  may  be  tried. 


CHAPTER    11. 

DISEASES    OF    THE    GASTRO-INTESTINAL 
AND    BILIARY    TRACTS. 

Case  31.  Man,  fifty  years  old,  a  hard  drinker,  except  dur- 
ing the  past  year.  No  family  history  obtained.  For  two  or 
three  years  he  has  had  pain  after  taking  food,  occasional 
vomiting,  and  progressive  loss  of  flesh  and  strength.  For  the 
past  eight  or  ten  weeks  he  has  complained  of  frequent  and 
severe  pain  of  a  "  stretching  "  character  in  the  right  hypo- 
chondrium,  without  much  tenderness  there.  For  the  last  two 
weeks  he  has  been  deeply  jaundiced.  For  a  week  he  has  been 
confined  to  bed  and  is  emaciated  and  prostrated.  His  nights 
are  disturbed  by  pain.  The  liver  is  greatly  enlarged,  hard, 
irregular,  and  nodulated,  the  lower  edge  reaching  to  the  an- 
terior spine  of  the  ilium ;  it  also  extends  to  the  jeft  of  the  median 
line  about  two  inches.  It  is  slightly  tender.  There  is  little 
or  no  ascites.  Pulse  92;  temperature  98.5°.  Urine  rather 
scanty  and  very  dark.     No  itching  of  skin. 

1.  What   diseases   can   produce   emaciation   with   jaundice? 

Gall-stones  and  their  results,  cancer  obstructing  the 
biliary  passages,  syphilis  of  the  liver,  cirrhosis,  septi- 
caemia (toxaemic  jaundice). 

2.  Common  causes  of  hepatic  enlargement?     Passive  conges- 

tion, biliary  obstruction  from  any  cause,  fat,  cirrhosis, 
cancer,  rickets;  rarer  causes  are  abscess,  leucaemia  and 
pseudoleucaemia,  cholangeitis,  amyloid,  and  hydatid 
disease. 

3.  What  importance  would  there  have  been  in  a  good  family 

history?  None  in  this  case.  (The  diseases  in  which 
the  family  history  is  of  value  may  here  be  emphasized.) 

Diagnosis:  Gastric  symptoms,  nodular  hepatic  enlarge- 
ment with  severe  pain,  emaciation,  and  jaundice,  and  without 
evidence  of  portal  stasis  (ascites,  etc.),  point  strongly  to  cancer 
of  the  liver,  probably  secondary  to  gastric  cancer.  The  history 
of  alcoholism  and  the  hepatic  enlargement  suggest  cirrhosis, 

97 


98  CASE   HISTORIES   IN   MEDICINE. 

but  there  is  rarely  if  ever  so  much  pain  in  cirrhosis  (or  indeed 
in  any  Hver  disease  except  cancer),  and  the  "  hobnails  "  of 
cirrhosis  are  not  large  enough  to  make  the  liver  feel  "  irregular 
and  nodular  "  through  the  abdominal  wall.  The  absence  of 
ascites  is  also  against  cirrhosis.  Syphilis  of  the  liver  might 
produce  all  the  signs  described  and  can  only  be  finally  elimi- 
nated by  the  therapeutic  test,  but  the  amount  of  pain  here 
present  is  almost  unknown  in  syphilis  and  the  amount  of 
hepatic  enlargement  is  very  unusual. 

Prognosis:  The  prognosis  of  gastric  cancer  is  almost  in- 
variably fatal.  Personally  I  have  never  known  a  recovery, 
even  after  the  most  favorable  type  of  operative  interference.^ 
As  a  rule  the  symptoms  last  from  eight  months  to  eighteen 
months  after  the  patient  first  begins  to  be  distressed.  Yet 
under  careful  diet  and  rest  very  marked  periods  of  improve- 
ment not  infrequently  occur,  especially  if  the  patient  is  given 
the  benefit  of  encouragement  and  frequent  lavage. 

Treatment:  Operation  should  be  advised  in  all  early  cases 
as  soon  as  the  diagnosis  is  made.  Unfortunately  there  are 
very  few  cases  which  can  be  truthfully  said  to  belong  in  this 
category.  The  diagnosis  is  usually  impossible  until  the  dis- 
ease is  advanced  beyond  the  stage  at  which  operative  measures 
can  furnish  any  considerable  measure  of  relief.  Cases  in 
which  a  tumor  is  palpable  are  very  rarely  benefited  by  opera- 
tion, which  should  nevertheless  be  undertaken,  in  my  opinion, 
in  practically  every  case,  because  of  the  possibility  that  the 
tumor  may  not  really  be  cancer  at  all,  but  may  represent 
a  thickening  about  the  site  of  a  peptic  ulcer.  I  have  known  a 
number  of  cases  in  which  an  expert  was  unable  to  distinguish 
a  cancerous  tumor  from  the  perigastritis  associated  with  ulcer, 
even  when  the  abdomen  was  open  and  the  mass  exposed  to 
sight  and  touch.  Indeed  even  the  histological  examination 
of  an  excised  gland  not  infrequently  leads  to  false  conclusions. 

For  these  reasons  it  seems  to  me  that  operation  should  be 
advised  in  almost  every  case  even  though  we  may  believe,  as 
I  do,  that  in  genuinely  cancerous  cases,  it  is  rarely  of  value. 

^  The  extensive  statistics  of  the  Mayos'  clinic  show  i  pa- 
tient alive  10  years  after  operation.  Collected  Papers  of  the 
Mayo  Clinic,  p.  122. 


Plate  II. 

Bismuth-X-ray  picture  of  a  stomach  on  the  greater  curvature  and  pos- 
terior surface  of  which  (at  C)  a  cancerous  infiltration  was  found  at  operation, 
Dotted  Hne  shows  roughly  the  lower  limit  of  the  organ.  D  =  Diaphragm, 
with  stomach  bubble  beneath,  P  =  Pylorus,  L  =  Upper  border  of  liver. 
(Crayon  drawing  by  Ruth  C.  Huestis  from  X-ray  plate.) 


DISEASES   OF  GASTRO-INTESTINAL   AND   BILIARY   TRACTS.     99 

If  operation  is  refused  or  if  no  competent  surgeon  is  at 
hand  to  perform  it,  our  treatment  consists  in  overcoming  the 
bad  results  of  stasis  through  daily  lavage,  and  selecting  a  diet 
which  will  provide  the  maximum  of  nutrition  and  the  mini- 
mum of  gastric  irritation.  In  almost  every  case  meat  is  the 
most  objectionable  of  all  foods,  and  has  to  be  excluded  from 
the  diet.  Aside  from  this  there  is  no  single  food  which  is  not 
well  borne  by  certain  patients,  and  one's  plan  of  action  has 
to  be  determined  experimentally.  The  administration  of 
dilute  hydrochloric  acid,  10  to  20  minims  during  the  course 
of  each  meal,  seems  to  help  some  patients,  possibly  by  its 
action  in  stimulating  the  flow  of  pancreatic  secretion.  It  is 
hard  to  believe  that  the  amount  of  acid  we  can  administer  as 
a  therapeutic  can  have  any  considerable  value  in  the  stomach 
chemistry. 


100  CASE   HISTORIES   IN   MEDICINE. 

-  Case  32.  A  married  lady,  childless,  fifty-five  years  old,  of 
good  family  history,  is  seen  in  February,  1900.  She  passed 
the  menopause  without  difficulty,  and  several  years  ago  had 
cystitis,  with  good  recovery.  During  the  winter  of  1899  she 
traveled  in  North  Africa,  going  to  Germany  toward  spring. 
There  her  appetite  became  capricious  and  she  suffered  occa- 
sionally from  slight  nausea,  without  vomiting.  She  then 
had  an  attack  of  "grippe,"  which  much  impaired  her  strength. 
In  the  early  summer  she  returned  home,  when  her  appetite 
and  digestion  improved  much,  and  her  strength  returned  in 
great  measure,  though  her  friends  remarked  that  she  was  dis- 
tinctly paler  than  formerly.  She  considered  herself  well 
enough  until  five  months  ago,  when  she  began  to  suffer  from 
sciatica,  at  first  and  more  severely  in  the  right  side,  but  later 
also  in  the  left.  About  a  month  later  her  appetite  failed  again 
and  more  or  less  constant  nausea  came  on,  with  occasional 
vomiting,  the  latter  without  relief  or  definite  relation  to  either 
the  time  of  taking  food  or  its  quality.  Then  came  on  very 
troublesome  salivation,  leading  her  constantly  to  spit  up  a 
clear,  somewhat  frothy  fluid,  which  is  sometimes  poured  out 
in  such  quantity  as  to  run  from  her  mouth.  This  persists  to 
the  present  time.  The  sciatic  pain  now  has  practically  dis- 
appeared. She  has  kept  her  bed  for  some  weeks,  losing  flesh 
(though  she  is  still  stout),  but  sleeping  well.  Of  late  there 
has  been  slight  bleeding  from  the  gums,  but  no  other  haemor- 
rhage has  been  noted. 

Pulse  96,  regular,  soft;  temperature  99°,  above  which  point 
it  is  said  not  to  have  risen.  Except  for  marked  pallor,  physical 
examination  is  negative.  The  urine  is  negative  and  contains 
no  arsenic.  Several  examinations  of  the  gastric  contents 
show  neither  free  HCl  nor  lactic  acid. 

An  examination  of  blood  slides  shows:  Red  cells  3,000,000 
or  thereabouts;  white  15,000;  Hg  relatively  low. 

Reds:  Marked  achromia,  slight  deformities,  no  polychro- 
matophilia,  average  diameter  normal,  one  normoblast. 

Whites:  Polymorphonuclear  80%;  lymphocytes  20%; 
eoslnophiles  0%. 


DISEASES    OF   GASTRO-INTESTINAL   AND    BILIARY   TRACTS.      10 1 

1 .  What  types  of  anaemia  are  of tenest  seen  at  55  ?     Pernicious 

anaemia,  and  that  secondary  to  cancer,  metrorrhagia  or 
other  haemorrhage. 

2.  What    diseases    are    of  tenest    diagnosed     (wrongly)     as 

"  grippe  "?  Tuberculosis,  febrile  gastro-enteritis,  ton- 
silitis  and  pharyngitis,  bronchitis,  bronchopneumonia, 
and  many  infections  not  yet  named. 

3.  Significance  of   the  absence  of  free   HCl   in   the  gastric 

contents  ?  It  may  be  temporarily  absent  in  many  con- 
ditions and  often  without  any  known  cause.  Perma- 
nent absence  of  HCl  is  commonest  in  diabetes,  gastric 
cancer,  gastric  catarrh,  and  other  chronic  dyspepsias, 
and  pernicious  anaemia. 

4.  What  further  information  about  the  stomach  is  needed 

here?     Its  size  and  motor  power. 

Diagnosis:  The  cause  of  the  marked  anaemia  here  present 
should  be  looked  for  in  one  of  the  following  diseases:  Intes- 
tinal parasites,  myxoedema,  malignant  disease,  pernicious  anae- 
mia. Myxoedema  Is  suggested  only  by  the  salivation  and 
can  be  ruled  out  by  the  therapeutic  test.  The  stools  should  be 
searched  for  eggs  of  intestinal  parasites.  Careful  pelvic  and 
abdominal  examination  should  be  made  under  ether  or  in  a 
warm  bath  in  search  for  a  focus  for  malignant  disease.  The 
blood  Is  not  typical  of  pernicious  anaemia,  but  is  consistent 
with  that  disease  in  a  period  of  remission.  Diagnosis  is 
Impossible  from  the  data  here  given.  (Later  in  the  case  evi- 
dences of  gastric  cancer  appeared.) 

Prognosis:  The  outlook  is  almost  hopeless,  though  early 
operation  saves  some  cases.  As  a  rule  life  is  not  prolonged 
beyond  two  years,  but  after  careful  diet,  with  or  without 
gastro-enterostomy,  a  great  Improvement  may  occur  for  a 
few  months. 

Treatment:  Careful  diet  and  lavage  produce  striking  tem- 
porary improvement  in  some  cases.  The  administration  of 
HCl  is  apparently  of  value.  In  all  doubtful  or  early  cases 
operation  should  be  advised  (see  Case  31). 


102  CASE   HISTORIES   IN   MEDICINE. 

Case  33.  A  sailor,  thirty-nine  years  old,  is  seen  on  No- 
vember 5.  His  mother  died  of  "  stomach  trouble."  Has 
had  gonorrhoea  three  times,  and  ten  years  ago  a  sore  on  his 
penis.  No  secondary  symptoms  were  observed.  Always 
well  up  to  two  years  ago,  when  he  began  to  have  epigastric 
pain  after  eating.  He  vomited  frequently  and  usually  with 
Telief  of  pain.  After  three  months  in  a  hospital,  he  improved 
somewhat,  but  after  discharge  the  old  symptoms  returned 
and  with  them  headache  and  alternate  constipation  and 
diarrhoea.  He  again  entered  a  hospital  and  remained  six 
months,  but  lost  strength  and  weight  steadily  and  vomited 
everything  taken.  The  vomitus,  occasionally  amounting  to 
a  quart  at  a  time,  was  often  "  dark  in  color,  and  now  and 
then  contained  a  streak  of  blood."  The  patient  is  much 
prostrated  and  emaciated.  The  abdomen  is  retracted,  but 
more  prominent  in  the  epigastrium,  where  there  is  some 
rigidity  of  the  muscles  and  a  little  tenderness.  Physical  ex- 
amination is  otherwise  negative.  Pulse  no,  respiration  18, 
temperature  98°.  Urine  1020,  alkaline,  no  albumin,  no  sugar. 
The  inflated  stomach  extends  from  the  normal  limit  above,  to 
an  inch  below  the  umbilicus.  Its  capacity  is  fifty- four  ounces. 
Two  days  ago,  an  hour  after  a  test  breakfast  of  one  ounce  of 
bread  and  ten  ounces  of  water,  twenty  ounces  of  brownish 
fluid,  containing  much  mucus,  were  withdrawn.  Free  HCl 
and  blood  absent.  Lactic  acid,  intense  reaction.  Butyric 
present.  This  morning  the  stomach  was  washed  out  again, 
and  a  pint  of  oat-gruel  was  given.  An  hour  and  a  quarter 
later  twenty  ounces  were  withdrawn  which  contained  con- 
siderable mucus  but  no  blood.  Free  HCl  absent;  combined, 
present  in  small  quantity.  Lactic  acid,  a  trace.  Total  acid- 
ity, .237.  The  leucocytes,  before  eating,  numbered  5600; 
after,  7300.  The  stomach  after  inflation  extended  from  the 
normal  limits  above  to  a  point  an  inch  below  the  umbilicus. 
Its  capacity  was  fifty-seven  ounces. 

1 .  How  many  ounces  of  fluid  does  the  normal  stomach  hold  ? 

About  forty-eight. 

2.  Significance  of  mucus  in  the  stomach  content  ?     Mucus  is 

always  present  in  the  stomach.     By  practice  with  many 
cases  needing  gastric  lavage,   one  learns  to  recognize 


DISEASES    OF   GASTRO-INTESTINAL   AND    BILIARY   TRACTS.      IO3 

ho\v  much  mucus  is  to  be  extracted  from  the  normal 
stomach,  and  hence  to  recognize  marked  excess  sug- 
gesting catarrh. 

Diagnosis :  Gastric  pain  and  vomiting  (the  vomitus  bloody, 
and  sometimes  a  quart  in  amount),  loss  of  flesh  and  strength, 
evidences  of  gastric  dilatation  and  stasis,  and  the  continued 
absence  of  HCl  all  point  towards  pyloric  cancer.  The  scar 
of  an  ulcer  near  the  pylorus  (peptic  or  syphilitic)  might,  by 
contraction  and  obstruction  of  the  pylorus,  bring  about  gas- 
tric dilatation,  stasis,  and  the  other  symptoms  of  this  case; 
but  the  continued  absence  of  HCl,  the  absence  of  hemoptysis, 
and  the  age,  make  gastric  cancer  more  likely. 

Prognosis  and  Treatment :  (see  above.  Case  31). 


104  CASE   HISTORIES    IN    MEDICINE. 

Case  34.  Dentist,  forty- two  years  old,  always  well  until 
within  four  days,  when,  after  a  hard  day's  work,  was  taken 
with  a  chill,  vomiting,  and  epigastric  pain.  Temperature 
102°.  Next  day,  99.4°,  but  vomiting  continued  and  was  so 
exhausting  that  J  gr.  of  morphia  was  given  subcutaneously. 
Pain  not  so  severe  as  the  night  before,  but  considerable  epi- 
gastric tenderness.  Kept  his  bed.  Temperature  101.4°  in 
afternoon. 

On  the  third  day,  the  one  previous  to  that  on  which  I  saw 
him,  the  vomiting  was  less  persistent  and  temperature  a 
little  lower,  but  he  felt  very  weak  and  faint,  wanted  no  light 
or  sound  in  his  room,  and  desired  to  be  left  alone  and  not 
disturbed.  Slight  tenderness  over  the  whole  abdomen  now 
developed,  with  perhaps  a  little  more  on  the  right  iliac 
region.  Bowels  have  been  moved  freely  by  cathartics  each 
day.  To-day,  feels  as  if  there  was  a  mass  in  the  rectum. 
Urine  very  scanty  in  the  last  three  days.  It  was  examined 
a  week  ago  and  found  normal.  There  has  been  no  oedema. 
Has  been  working  very  hard  of  late. 

Examination:  Tongue  clean;  temperature  99.2°  at  5  p.m.; 
pulse  68,  good  strength.  The  patient  is  pale,  and  looks 
exhausted  and  in  pain.  Thorax  negative.  Slight  general  ab- 
dominal tenderness,  not  localized,  but  slightly  greater  in  the 
epigastrium.     Rectal  examination  negative. 

1.  What  is  the  significance  of  the  mass  apparently  felt  in 

the  rectum?     Any  rectal  Irritation  may  give  the  feel- 
ing as  if  a  mass  were  present. 

2.  Why  is  the  urine  so  scanty?     Presumably  because  of  the 

persistent  catharsis. 

3.  What  further  tests  should  be  made?     Leucocyte  count, 

urine  examination. 

Diagnosis :  Has  he  or  has  he  not  a  localized  peritonitis  — 
perhaps  from  appendicitis?  In  favor  of  peritonitis  are  the 
initial  temperature  and  the  suggestion  of  localized  tenderness 
on  the  third  day.  Against  it  are  the  absence  of  localized 
tenderness  or  elevated  pulse  upon  the  fourth  day,  the  free 
movements  of  the  bowels,  the  mental  condition,  and  (to  some 
extent)  the  temperature.  The  presence  or  absence  of  leuco- 
cytosis  would  help  to  decide  the  question.     It  is  conceivable 


DISEASES    OF   GASTRO-INTESTINAL   AND    BILIARY    TRACTS.      IO5 

that  a  nephritis  with  ursemia  may  have  declared  itself  within 
the  week  since  the  urine  was  last  examined.  The  photo- 
phobia suggests  meningitis  or  hysteria,  but  there  are  no  other 
data  confirming  these  hints.  Previous  to  obtaining  a  leuco- 
cyte count  and  urinary  examination,  acute  indigestion,  aggra- 
vated by  cathartics  and  by  fear  of  appendicitis,  seemed  the 
most  probable  diagnosis.  Leucocytes  and  urine  proved  nor- 
mal and  the  diagnosis  just  mentioned  became  still  more  prob- 
able.    The  course  of  the  case  confirmed  it. 

Prognosis:  He  should  be  well  and  at  work  w^ithin  a  week. 
The  malady  is  trifling. 

Treatment:  To  convince  one's  self  and  then  the  patient 
that  he  has  no  appendicitis  or  other  serious  disease,  to  stop 
the  cathartics  and  soothe  the  rectum  with  an  enema  of  thin 
cooked  starch,  to  get  the  patient  out  of  bed  and  gradually 
increase  his  diet  are  the  main  indications.  Nux  and  gentian 
will  probably  help  him,  also  advice  about  hygiene. 


I06  CASE   HISTORIES    IN   MEDICINE. 

Case  35.  A  factory  overseer  of  sixty-three  had  long  been 
subject  to  constipation,  and  for  two  years  had  had  right 
inguinal  hernia.  Otherwise  his  previous  history  was  excellent. 
On  the  day  before  his  illness  he  had  what  he  regarded  as  a 
satisfactory  movement  of  the  bowels.  That  night  he  ate 
heartily  of  clam  chowder  and  strawberries.  The  next  after- 
noon he  felt  some  abdominal  discomfort.  Later,  while  taking 
a  bath,  he  found  his  hernia  was  down  (as  he  had  taken  the 
truss  off),  and  found  more  difficulty  than  usual  in  replacing 
it.  That  night  he  vomited  many  times,  the  first  vomitus 
suggesting  strawberries,  and  had  great  abdominal  pain,  not 
localized.  When  seen  next  morning  at  4  A.M.,  he  was  not 
collapsed.  The  tongue  was  moist,  with  a  slight  white  coat. 
Temperature  98.4°,  pulse  60,  respiration  14.  The  abdomen 
was  soft,  not  tender.  The  hernia  was  found  to  be  perfectly 
reduced.  Nothing  abnormal  was  felt  per  anum.  The  pain 
required  an  injection  of  morphia,  gr.  |.  Nausea  was  so 
troublesome  that  the  patient  refused  even  bits  of  ice.  Noth- 
ing whatever  passed  the  bowels.  On  the  second  day  the 
vomiting  became  stercoraceous.  On  the  third  day  the  vomit- 
ing persisted.  Temperature  98.5°,  pulse  68.  Large  enemata 
(5^  quarts)  had  been  given  without  apparent  benefit.  The 
belly  was  distended,  rather  hard,  not  tender.  In  the  right 
side  an  ill-defined  resistance  was  felt,  corresponding  to  the 
ascending  colon. 

1.  What  cause  can  you  suggest  for  the  slow  respiration  in 

this  case  ?     Possibly  he  has  already  been  given  morphia. 

2.  How  does  the  temperature  record  help  us  here  ?     It  tends 

to  exclude  peritonitis. 

3.  Causes  of  pyrexia  and  of  subnormal  temperature?  (a)   In- 

fections with  or  without  inflammation;  (b)  toxaemia 
(e.g.,  in  eclampsia) ;  (c)  disturbance  of  heat-regulation, 
as  in  sunstroke ;  {d)  after  use  of  atropin  and  in  nerv^ous 
excitement.  Subnormal  temperature  in  a  measure  of 
the  degree  of  prostration  from  any  exhausting  or  wast- 
ing disease  (nephritis,  cancer,  heart  disease,  myxoedema). 

4.  Is  the  combination  of  clam  chowder  and  strawberries  a 

particularly  indigestible  mixture  ?  What  is  its  probable 
relation  to  this  case  ?  Not  in  a  normal  stomach.  Prob- 
ably no  relation  to  this  case. 


DISEASES   OF   GASTRO-INTESTINAL   AND    BILIARY   TRACTS.      10/ 

5.  Causes  of  stercoraceous  vomiting  ?     Intestinal  obstruction 

and  general  peritonitis. 

6.  What  can  be  inferred  from  the  results  of  the  enemata  In 

this  case?  That  the  obstruction  is  above  the  sigmoid 
flexure. 

7.  Significance  of  the  tongue  in  disease  ?     In  this  case  ?     A 

coated  tongue  has  little  diagnostic  significance  in  gen- 
eral or  in  this  case,  since  it  Is  present  In  so  many  condi- 
tions of  health  and  disease.  A  clean  tongue  with 
dyspeptic  symptoms  suggests  hyperchlorhydria,  peptic 
ulcer  or  extra-gastric  disease. 

Diagnosis:  Intestinal  obstruction  is  obviously  present. 
Its  cause  might  be  the  hernia  reduced  "  en  bloc,"  but  from  the 
shortness  of  its  stay  outside  the  body  this  is  unlikely.  At 
this  patient's  age  cancer  is  by  far  the  commonest  cause  of 
obstruction.  The  acute  onset  of  symptoms  without  previous 
constipation  or  other  complaints  is  not  surprising,  for  It  is 
well  known  that  cancerous  stricture  may  suddenly  "  shut 
down  "  after  existing  for  months  without  symptoms.  The 
mass  In  the  ascending  colon  is  probably  feces  collected  be- 
hind a  cancer  at  the  hepatic  flexure. 

Prognosis :  Cancer  of  the  large  intestine  grows  as  slowly  as 
any  form  of  epithelioma  known  to  medical  science  unless  it 
be  that  occurring  on  the  lower  lip.  I  am  confident  that  such 
cases  may  live  in  very  tolerable  comfort  for  three  years  or 
more  before  the  malady  is  discovered.  Even  after  that  time 
Its  advance  and  the  occurrence  of  metastasis  is  very  slow. 
If  operation  is  promptly  and  successfully  performed  we  may 
hold  out  a  genuine  prospect  of  recovery.^ 

Treatment:  There  is  no  excuse  for  advising  any  treatment 
other  than  surgery  when  the  diagnosis  is  clear.  Should  opera- 
tion be  refused  our  efforts  are  limited  to  measures  for  empty- 
ing the  bowels  and  for  preventing  the  occurrence  of  such, 
accumulations  or  irritations  as  lead  to  a  "  shutting  down  " 
of  the  stricture.  Presumably  the  symptoms  of  acute  ob- 
struction which  occur  in  so  many  cases  are  due  not  simply 
to  the  mechanical  blocking  of  the  intestine  by  the  growth,  but 
to  an  additional  element  of  irritation  and  muscular  spasm 

^  Mayo  Clinic;  Collected  Papers,  pages  258-9. 


I08  CASE   HISTORIES   IN   MEDICINE. 

occasioned  by  some  temporary  source  of  irritation.  A  diet 
containing  the  smallest  amount  of  irritating  matter  that  is 
consistent  with  daily  movements  of  the  bowels  should  be 
prescribed,  and  the  patient  should  be  cautioned  never  to 
allow  a  day  to  pass  without  securing  some  sort  of  evacuation, 
using  an  enema  for  the  purpose  if  that  is  necessary.  Perfect 
regularity  of  life  and  the  avoidance  of  special  strains  and 
sources  of  fatigue  are  advisable. 


DISEASES   OF  GASTRO-INTESTINAL   AND    BILIARY   TRACTS.      IO9 

Case  36.  A  rather  nervous  gentleman,  forty-three  years 
old,  both  of  whose  parents  died  of  cancer,  moved  from  the 
city  to  the  country  about  a  year  before  his  present  illness 
began,  and  became  quite  active  outdoors,  with  benefit  to  his 
appetite  and  general  health.  The  winter  snows,  however, 
forced  him  to  be  more  sedentary.  When  first  seen  in  con- 
sultation with  the  family  physician,  who  had  been  called  only 
four  days  before,  he  complained  of  obstinate  constipation. 
For  six  weeks  he  had  had  darting  pains  in  the  lower  abdomen, 
worse  at  night,  but  relieved  by  walking.  The  physician  had 
first  prescribed  a  laxative  pill,  which  caused  pain  but  no  de- 
jection. The  next  night  he  sat  bending  forward  in  pain  most 
of  the  night,  getting  relief  from  a  hypodermic  of  |  grain  of 
morphia,  twice  repeated;  this  was  followed  by  a  fecal  dis- 
charge. The  bowels  were  soft,  except  for  resistance  corre- 
sponding to  the  ascending  and  transverse  colon.  The  next 
night  he  had  an  ounce  each  of  glycerin  and  castor  oil,  but 
was  worse  the  following  day.  Some  flatus  escaped  on  the  day 
of  the  consultation,  but  no  fecal  matter  had  come  away  for 
at  least  four  days.  The  temperature  had  remained  normal. 
There  was  no  vomiting. 

Physical  examination  showed  a  spare  man,  with  an  anxious 
face.  Rectal  examination  was  negative.  The  abdomen  was 
distended  with  gas  and  somewhat  tense,  but  nowhere  es- 
pecially tender.  When  the  patient's  attention  was  diverted, 
the  resistance  already  described  could  be  felt.  The  pulse 
was  not  remarkable  at  first,  but  after  the  examination  it 
became  rapid  and  feeble,  improving  again  after  a  little  brandy. 

1.  What  special  significance  has  the  effect  of  the  morphia  in 

this  case?  When  morphia  produces  a  fecal  movement 
it  does  so  by  relieving  spasm.  Such  spasm  is  apt  to 
occur  above  a  stricture  (cancerous  or  other)  of  the  gut. 

2.  What  can  be  inferred  from  the  rectal  examination  here? 

That  there  is  no  obstruction  within  reach  of  the  ex- 
aminer's finger. 

3.  How  do  you   interpret  the  absence  of  vomiting?     The 

obstruction  is  not  complete  (gas  passes)  and  is  probably 
low  down  in  the  large  gut. 

4.  Why  were  his  pains  relieved  by  walking  ?     The  element  of 

spasm  above  mentioned  may  have  been  helped  by  walk- 
ing, as  any  form  of  constipation  may  be. 


no  CASE   HISTORIES    IN   MEDICINE. 

Diagnosis:  Gradually  increasing  constipation,  leading 
finally  to  complete  stoppage  of  fecal  movements,  with  abdomi- 
nal distention,  pain,  and  a  pulse  that  easily  becomes  rapid  and 
feeble,  all  point  to  intestinal  obstruction,  apparently  in  the 
region  of  the  splenic  flexure  of  the  colon,  behind  which  feces 
are  accumulated.  At  his  age,  and  in  the  absence  of  any  his- 
tory of  previous  peritonitis  or  laparotomy,  cancer  of  the  bowel 
is  the  commonest  cause. 

Prognosis:  Grave;  operation  may  relieve,  but  early  recur- 
rence is  the  rule. 

Treatment:  Immediate  laparotomy,  artificial  anus;  later 
an  attempt  to  extirpate  the  growth  (see  Case  35). 


DISEASES   OF   GASTRO-INTESTINAL   AND    BILIARY    TRACTS.      Ill 

Case  37.  A  gentleman  of  eighty- twp  is  seen  April  17.  He 
has  always  enjoyed  good  health,  except  that  a  number  of 
years  ago  he  suffered  from  attacks  of  pain  in  the  right  upper 
abdomen,  diagnosed  as  bilious  colic;  for  this  pain  he  kept 
morphin  constantly  on  hand.  During  the  past  year  he  has 
aged  rapidly,  but  he  attended  to  business  regularly  until  a 
month  ago,  when  painless  jaundice  came  on  and  rapidly 
deepened,  the  stools  being  clay-colored.  A  week  ago  the 
jaundice  seemed  less  and  some  color  was  seen  in  the  dejections, 
but  this  was  only  temporary.  The  appetite  and  digestion 
have  been  fair;  he  smokes  a  good  deal.  He  has  been  up  until 
to-day,  when  increasing  weakness  induced  him  to  remain  in 
bed.  Pruritus  has  interfered  much  with  sleep.  The  tem- 
perature has  been  normal  until  to-day,  when  100°  was  regis- 
tered. The  pulse  has  been  regular,  about  70;  yesterday  it 
was  irregular  and  intermittent. 

When  seen,  he  was  sleeping  in  the  right  dorsal  decubitus, 
with  easy  respiration;  pulse  68,  regular,  of  fair  strength  and 
volume.  Icterus  intense,  the  tongue  heavily  coated,  the  mind 
clear. 

Thoracic  examination  gave  negative  results,  except  for 
slight  crepitus  at  the  right  posterior  base.  A  smooth  edge 
could  be  felt  below  the  right  costal  border,  descending 
with  inspiration,  not  tender.  The  gall-bladder  could  not  be 
felt.  Abdomen  soft,  otherwise  negative.  Urine  sufficient  in 
amount,  1018  in  specific  gravity,  deeply  icteric,  with  a  trace 
of  albumin,  hyalin  and  granular  casts. 

I.  Name  and  distinguish  five  common  varieties  of  colic. 
Biliary,  renal,  uterin,  intestinal  (including  saturnine) 
and  that  due  to  Dietl's  crises.  In  biliary  colic  the  pain 
is  apt  to  spread  from  the  region  of  the  gall-bladder  to 
the  back  and  right  scapular  region;  jaundice  may  appear 
before,  during,  or  after  the  attack.  In  renal  colic  the 
pain  follows  some  portion  of  the  course  of  the  ureter,  and 
is  often  associated  with  the  passage  of  blood  or  gravel 
by  urethra.  Uterin  colic  is  usually  associated  with  or 
precedes  flowing  —  menstrual  or  irregular  —  and  is 
referred  to  the  groins  or  pelvis.  Intestinal  colic  (if  not 
saturnine)  is  associated  with  diarrhoea  or  flatulence.  It 
shifts  its  position  frequently.     Lead  colic  is  recognized 


112  CASE   HISTORIES   IN   MEDICINE. 

only  by  association  with  other  evidence  of  lead  (gums, 
blood,  brain,  extensor  muscles).  Dietl's  crises  are 
recognized  only  by  the  association  of  abdominal  pain 
with  the  presence  of  a  floating  kidney  and  the  absence 
of  the  signs  of  other  colics. 

2.  What  significance  has  the  fact  that  the  gall-bladder  is  not 

felt  here?  A  gall-bladder  not  tense  with  fluid  cannot 
be  felt,  whatever  its  size,  and  the  belly  walls  often  pre- 
vent any  satisfactory  exploration  of  this  region.  Hence 
negative  evidence  is  of  little  value. 

3.  What  cerebral  symptoms  are  likely  to  appear  later  in  this 

case  ?  Coma,  delirium,  vomiting,  and  convulsions  — 
as  in  uraemia. 

4.  When  a  patient  ages  rapidly  what  disease  is  probable? 

Arteriosclerosis. 

Diagnosis,  Prognosis,  and  Treatment:  (see  Cases  38  and 
39).  Autopsy  showed  cancer  of  the  bile  duct  near  duodenal 
papilla. 


DISEASES   OF  GASTROINTESTINAL   AND    BILIARY   TRACTS.      II3 

Case  38.     A  liquor  dealer,  forty-seven  years  old,  is  seen 
December  15,  1904.     His  father  died  at  sixty-seven  of  "  ob- 
struction of  the  bowels,"  his  mother  at  sixty-three  of  pneu- 
monia.    He  regularly  used  whiskey  and  beer  to  excess  up  to 
1 89 1,  when  he  had  an  attack  of  bloody  vomiting  after  a  de- 
bauch.    He  had  a  similar  attack  in  1895  and  again  in  1902. 
He  never  was  kept  in  bed  more  than  a  few  days,  and  always 
returned  to  business  within  a  week.     After  each  attack  he 
gave  up  all  alcohol  for  periods  varying  from  six  months  to 
two  years  and  then  relapsed  into  his  former  habits.     He  has 
suffered  for  years  from  digestive  disturbances,  "  sour  stom- 
ach,"  which  have  been   much  worse  during  his  periods  of 
alcoholism.     After  twenty  months  of  abstinence  he  began  to 
drink  about   three   months   ago,   and   since   then   has   com- 
plained  of   anorexia,   pain,    eructation   of  gas,    nausea,    and 
vomiting.     The  pain   is  located   in   the  epigastrium,   comes 
on  ten   to   fifteen   minutes   after  eating,   and   is  relieved  by 
vomiting.     On   the   afternoon   of   December   11    he  vomited 
a   small   quantity  of    bright-red   blood,    and   since   then   he 
has  vomited    after   nearly  every  meal,  but   he   has  noticed 
blood  only  on   one   other   occasion,  two   days  ago,  when  he 
threw  up  nearly  a  pint.     He    has    noticed  black  stools  for 
several  days.     He  has  recently  lost  about  15  pounds;  present 
weight  185. 

Mucous  membranes  pale.  Heart  normal  in  size,  action 
regular,  soft  systolic  murmur  at  apex,  not  transmitted.  Pul- 
monic second  sound  not  accentuated.  Abdomen  tympanitic 
throughout,  slight  tenderness  on  pressure  over  epigastrium. 
Liver  dulness  extends  from  fifth  interspace  to  two  fingers' 
breadth  below  costal  margin  where  a  smooth  edge  can  be 
felt.  Lower  edge  of  spleen  felt  on  full  inspiration.  Physical 
examination  otherwise  negative.  Pulse  100,  regular,  of  good 
quality.  Temperature  98.4°.  Urine,  specific  gravity  1020, 
acid,  no  sugar,  no  albumin,  Hg  50%,  red  cells  3,172,000,  no 
nucleated  cells.     Leucocytes  9200. 

1.  What  is  the  type  of  ansemia  in  this  case?     Typical  sec- 

ondary. 

2.  Significance  of  the  patient's  family  history  ?     None  what- 

ever. 


114  CASE   HISTORIES   IN   MEDICINE. 

3.  What  causes  produce  tarry  stools  ?     Bismuth,  iron,  black- 

berries, blood  from  high  up  in  gut. 

4.  How  do  you   interpret  the  cardiac  signs  here  present? 

Functional  murmur. 

5.  What  are  the  commonest  causes  of  splenic  enlargement? 

Typhoid,  malaria,  rickets,  cirrhosis,  leucaemia,  anaemia. 

6.  What  causes  of  haematemesis  should  be  considered  here? 

Gastric  or  duodenal  ulcer,  cirrhosis,  aneurism. 

Diagnosis:  Hepatic  cirrhosis,  ruptured  oesophageal  varix, 
secondary  anaemia,  passive  congestion  of  stomach. 

Prognosis :  Unless  the  duration  of  the  case  is  prolonged  by 
operative  treatment,  the  length  of  life  Is  not  apt  to  exceed 
one  year  after  the  appearance  of  ascites  and  other  evidence 
of  portal  stasis.  The  disease  remains  for  many  years  latent 
or  compensated,  but  when  it  once  makes  its  appearance  in 
a  form  capable  of  recognition  at  the  bedside,  its  course  is 
usually  rapid  and  severe. 

Treatment:  I  have  never  seen  any  striking  improvement 
follow  an  abstinence  from  alcohol.  In  the  majority  of  cases 
the  patients  have  given  up  the  habit  before  they  came  under 
the  physician's  management.  If  this  is  not  the  case  the  drug 
should  be  prohibited  at  once. 

In  my  opinion  it  Is  our  duty  to  treat  every  case  with  potas- 
sic  lodid  and  mercury,  recognizing  as  we  must  the  possibil- 
ity of  a  syphilitic  basis  for  the  disease  and  the  impossibility 
of  excluding  this  by  physical  examination  or  by  history.  I 
have  known  two  cases  confidently  believed  to  be  of  the  or- 
dinary type  of  alcoholic  cirrhosis  yet  showing  swift  and 
permanent  improvement  after  anti-syphilitic  medication. 
Doubtless  such  cases,  however,  are  rare. 

After  excluding  syphilis  we  have  no  therapeutic  resources 
except  the  amelioration  of  the  patient's  local  discomforts  by 
repeated  tappings,  the  restitution  of  his  blood  mass  by  trans- 
fusion after  haemorrhage,  and  operative  procedures  for  estab- 
lishing a  collateral  circulation.  Although  this  latter  operation 
does  not  succeed  in  any  considerable  percentage  of  cases, 
it  seems  to  me  that  it  should  be  advised  in  practically  all 
patients  whose  general  condition  warrants  their  being  sub- 
jected to  anaesthesia  and  operative  shock.     This  is  all  the 


DISEASES   OF  GASTRO-INTESTINAL   AND   BILIARY   TRACTS.     II5 

more  justifiable  because  the  diagnosis  of  cirrhosis  of  the  liver 
is  one  of  which  we  can  rarely  be  certain  unless  the  abdomen 
has  been  opened.  Other  and  more  curable  causes  of  ascites 
may  be  present.  The  patient  should  therefore  be  given  the 
benefit  of  the  doubt  and  an  exploratory  laparotomy  advised 
in  almost  every  case.  Whether  a  further  operation  for  the 
restoration  of  a  collateral  circulation  shall  be  carried  out  in 
case  the  malady  proves  to  be  cirrhosis,  is  a  question  best 
determined  by  the  surgeon  when  the  liver  is  accessible  to 
sight  and  touch. 


Il6  CASE  HISTORIES   IN   MEDICINE. 

Case  39.  A  metal  polisher  of  fifty-five  entered  the  hos- 
pital December  10,  1910,  for  the  third  time.  H^s  first  entrance 
was  in  1879  when  he  was  operated  on  for  stricture  of  the 
urethra;  a  second  operation  was  done  for  the  same  trouble  in 
1884.  Otherwise  his  general  health  has  been  good.  He  had 
gonorrhoea  and  a  soft  chancre  in  1872,  took  alcohol  in  moder- 
ation until  last  summer  when  he  drank  heavily.  He  smokes 
and  chews  twenty-five  cents'  worth  of  tobacco  a  week. 

For  the  past  four  months  he  has  had  constant  dull  pain 
in  the  loins  with  irregular  exacerbations.  In  these  sharper 
attacks  the  pain  shoots  down  along  the  course  of  the  ureters, 
especially  the  right  ureter,  and  he  has  increased  desire  to 
urinate  with  no  relief  from  pain  after  urination. 

For  the  past  three  months  he  has  suffered  from  another 
pain,  a  dull,  gnawing  ache  at  the  pit  of  the  stomach,  coming 
on  immediately  after  meals  and  lasting  from  one-half  an  hour 
to  an  hour.  It  is  usually  relieved  by  taking  hot  water  or 
soda.  He  has  rarely  vomited  and  has  never  seen  any  blood 
in  the  vomitus.  His  bowels  are  very  constipated.  Although 
his  appetite  has  remained  good,  he  has  lost  23  pounds  in  the 
last  year  and  had  to  give  up  work  some  weeks  ago. 

The  patient  was  well-developed  and  nourished,  his  skin  and 
mucous  membranes  of  good  color.  Three  days  after  entrance 
jaundice  appeared  accompanying  an  attack  of  abdominal 
cramps.  The  chest  showed  nothing  abnormal.  Pulse  and 
reflexes  were  normal.  A  slight  tenderness  over  the  pubes  and 
in  the  left  iliac  fossa.  Sudden  pressure  under  the  right  cos- 
tal margin  caused  the  patient  to  wince.  Steady  pressure  pro- 
duced no  pain.  Otherwise  the  abdomen  was  normal.  Slight 
general  oedema  was  present.  Rectal  examination  showed  en- 
largement, hardness,  and  irregularity  of  the  prostate.  The 
temperature  was  98°,  the  pulse  84,  respiration  24;  urine  from 
25  to  40  ounces  in  twenty-four  hours,  specific  gravity  1026  with 
a  very  slight  trace  of  albumin,  no  sugar.  The  sediment  showed 
a  moderate  number  of  leucocytes  and  a  few  casts.  The  systolic 
blood  pressure  was  140.  Haemoglobin  75%,  leucocytes  6000, 
stained  smear  normal.  Wasserman  reaction  negative.  Three 
weeks  after  entrance  the  liver  was  felt  3  cm.  below  the  costal 
margin.      The  jaundice  was  still  intense.      The  capacity  of 


DISEASES    OF   G ASTRO-INTESTINAL   AND    BILIARY   TRACTS.      II7 

the  stomach  was  800  cm.,  and  on  inflation  the  lower  border 
reached  the  level  of  the  navel.  Examination  of  the  contents 
after  a  test  meal  showed  nothing  abnormal  and  before  break- 
fast the  stomach  was  shown  to  be  empty.  Although  the  pain 
was  somewhat  relieved  by  poulticing,  the  general  condition 
grew  slowly  worse  and  vomiting  more  frequent.  The  tem- 
perature was  never  above  99°  and  the  pulse  averaged  80. 
This  condition  of  things  went  on  from  December  10,  to 
February  14,  the  patient  gradually  losing  strength  and  weight 
throughout.  Then  the  temperature  rose  sharply  to  103°, 
the  patient  became  partially  unconscious,  and  died  three 
days  later. 

Diagnosis,  Prognosis,  and  Treatment:  Gall-stones  aftd 
cancer  are  the  affections  most  to  be  considered.  Unfortu- 
nately for  this  patient  the  condition  of  his  prostate  as  felt  by 
rectum  led  a  number  of  eminent  surgeons  to  a  very  positive 
belief  that  he  had  malignant  disease.  Consequently  he  was 
allowed  to  die  without  any  attempt  at  operative  interference. 
The  writer  repeatedly  urged  operation  on  the  ground  that 
gall-stones  was  a  perfectly  possible  diagnosis  and  that  the 
patient  should  be  given  the  benefit  of  the  doubt.  Autopsy 
showed  that  the  patient  died  of  gall-stones  and  the  result- 
ing toxaemia  associated  with  his  long-standing  and  intense 
jaundice.  This  is  the  second  case  that  I  have  known  to  die 
of  gall-stones  owing  to  faulty  diagnosis.  It  has  Impressed 
upon  me  very  strongly  the  Importance  of  exploratory  incision 
In  all  cases  In  which  the  diagnosis  of  gall-stones  Is  reasonably 
possible,  even  those  cases  in  which  the  weight  of  evidence  is 
against  it. 

The  case  also  demonstrates  that  patients  can  die  of  gall- 
stones independent  of  any  perforative  peritonitis  or  local 
sepsis.  The  death  in  this  case  was  apparently  due  to  exhaus- 
tion from  pain  and  auto-intoxication  associated  with  the  ob- 
struction of  the  biliary  flow.  The  rapid  emaciation  of  this 
patient  Is  notable  since  it  undoubtedly  went  to  support  the 
false  diagnosis  of  malignant  disease. 

Of  course  we  cannot  urge  operation  in  every  case  of  jaun- 
dice. When  free  fluid  Is  present  in  the  abdomen,  I  think  we 
can  exclude  uncomplicated  gall-stones.     In  the  vast  majority 


Il8  CASE  HISTORIES   IN   MEDICINE. 

of  cases  the  combination  of  free  fluid  and  jaundice  means 
malignant  disease,  cirrhosis  or  syphilis  of  the  liver,  and  in 
no  one  of  these  three  affections  can  it  be  said  that  operation 
is  imperatively  demanded.  It  is  in  cases  of  intense  jaundice 
without  ascites  that  we  should  be  very  chary  of  making  a 
diagnosis  which  excludes  the  possibility  of  surgical  inter- 
ference. 

At  autopsy  the  gall-bladder  was  found  greatly  enlarged  and 
so  crammed  with  gall-stones  that  it  compressed  the  common 
bile  duct,  producing  obstruction,  although  the  duct  was  not 
occupied  by  any  stone  or  cicatrix.  The  enlarged  gall-bladder 
also  pressed  upon  the  pylorus  and  caused  a  considerable 
degree  of  obstruction  at  that  point  and,  moreover,  the  gall- 
bladder exerted  pressure  upon  the  vessels  in  the  lower  omen- 
tum to  such  an  extent  that  very  marked  oedema  of  the 
stomach  wall  resulted.  The  wall  of  the  stomach  was  three- 
quarters  of  an  inch  thick. 


DISEASES   OF  GASTRO-INTESTINAL  AND    BILIARY   TRACTS.     II9 

Case  40.  The  patient  is  a  married  woman,  age  thirty- 
four,  large  and  fat  in  person.  She  has  had  two  children  and 
three  miscarriages,  the  last  six  weeks  ago.  Otherwise  she 
says  her  health  has  always  been  good,  until  within  three  or 
four  months;  has  been  in  the  habit  of  drinking  beer  freely, 
but  has  not  been  intemperate.  For  two  weeks  there  has  been 
pronounced  jaundice,  anorexia,  and  bilious  vomiting  soon 
after  eating;  dizziness,  flatulence,  occasional  diarrhoea  with 
pain  at  epigastrium ;  slight  oedema  of  feet  and  ankles.  These 
symptoms  have  been  increasing.  There  has  been  no  head- 
ache and  no  haemorrhages  or  chills. 

The  tongue  was  clean,  the  pulse  80,  temperature  97.8°. 
The  heart  and  lungs  were  normal.  The  liver  was  much 
enlarged  and  smooth.  The  spleen  was  felt  below  the  ribs. 
There  was  no  ascites.  The  urine  had  a  specific  gravity  of 
1 01 7,  was  of  a  deep  yellow  color,  and  contained  a  trace  of 
albumin  and  much  bile;  sediment  normal.  The  blood  was 
negative. 

1.  What  forms  of  jaundice  need  not  be  considered  in  this 

case?  The  toxaemic  forms  can  be  excluded.  This 
leaves  cancer  (probably  of  the  pancreas),  "catarrhal 
jaundice,"  syphilis,  cirrhosis. 

2.  What  can  we  infer  from  the  smoothness  of  the  liver  sur- 

face ?  That  cancer  of  the  liver  is  not  very  likely  to  be 
present.  Cirrhotic  elevations  and  depressions  are  not 
often  palpable  through  the  belly  wall.  Syphilis  often 
causes  great  deformities  of  the  liver. 

3.  In  what  types  of  hepatic  enlargement  is  pain  a  prominent 

symptom  ?  Chiefly  in  passive  congestion  and  in  cancer. 
Gall-stones  may  produce  much  pain,  but  do  not  often 
produce  demonstrable  hepatic  enlargement.  In  ab- 
scess there  is  no  pain  until  the  pus  has  burrowed  up 
close  to  the  surface  so  as  to  stretch  the  capsule  where 
lie  practically  all  the  nerves  of  the  liver.  Cirrhosis  is 
rarely  painful,  syphilis  often  painless. 

4.  What  are  the  significant  points  in  the  past  history  ?     The 

miscarriage  (which  suggests  syphilis),  the  alcoholism 
(which  suggests  cirrhosis),  the  build  (which  suggests 
gall-stones) . 

Diagnosis:  Gall-stone  in  the  common  duct  is  possible  but 
unlikely,  owing  to  the  presence  of  splenic  tumor,  the  lack  of 


120  CASE  HISTORIES   IN   MEDICINE. 

any  intermission  in  the  symptoms  and  the  absence  of  pain, 
fever,  or  chills.  Catarrhal  jaundice  cannot  be  excluded, 
though  it  rarely  leads  to  much  enlargement  of  the  liver  or 
spleen.  The  points  against  cancer  are  the  absence  of  pain, 
cachexia,  or  irregularities  on  the  liver  surface.  Syphilis  might 
produce  all  these  symptoms  and  can  be  positively  excluded 
only  by  the  therapeutic  test.  Cirrhosis,  or  the  combination  of 
cirrhosis  and  fatty  infiltration,  is  the  most  likely  diagnosis. 
This  accounts  better  than  any  other  hypothesis  for  the  splenic 
enlargement,  the  large,  smooth  liver,  and  the  jaundice.  The 
gastric  symptoms  would  then  result  from  passive  congestion 
of  the  stomach.  The  course  of  the  case  confirmed  the  diag- 
nosis of  cirrhosis. 

Prognosis  and  Treatment :  (see  Case  38). 


DISEASES    OF   GASTRQ-INTESTINAL   AND   BILIARY   TRACTS.      121 

Case  41.  A  watchman  of  twenty-three  entered  the  hospital 
February  26,  191 1.  Except  for  an  attack  of  jaundice  lasting 
three  weeks  two  years  ago,  he  has  always  been  well  and  his 
family  history  is  negative. 

Three  months  ago  he  was  in  a  hospital  for  three  weeks  on 
account  of  pain  in  the  right  upper  quadrant,  with  some  vomit- 
ing. The  diagnosis  then  made  was  "  possible  typhoid  fever." 
For  some  years  he  has  had  occasional  attacks  of  epigastric 
distress  coming  about  two  hours  after  meals  and  lasting  about 
twenty-four  hours  without  vomiting.  The  attacks  were 
usually  attributed  to  indiscretions  in  diet. 

Three  days  ago  he  had  sudden  and  very  severe  pain  in  the 
epigastrium  and  right  hypochondrium,  and  vomiting  of  bile- 
stained  fluid.  Pain  and  vomiting  have  continued  ever  since. 
The  bowels  did  not  move  until  last  night,  having  been  con- 
stipated for  the  three  previous  days. 

On  examination  the  chest  and  extremities  were  negative. 
The  abdomen  was  tense  and  generally  tympanitic,  except  for 
slight  shifting  dulness  in  flanks  and  flatness  in  the  right  hypo- 
chondrium, where  there  was  boardlike  rigidity  and  localized 
tenderness.  In  other  parts  of  the  abdomen  there  was  slight 
general  spasm.  The  temperature  was  100°,  pulse  no,  respi- 
ration 25;  the  leucocyte  count  16,000. 

Diagnosis :  The  diseases  chiefly  to  be  considered  are,  peptic 
ulcer,  inflammation  of  the  gall-bladder  with  or  without  stones, 
and  intestinal  obstruction.  Physical  examination  makes  it 
pretty  obvious  that  we  are  dealing  with  a  perforative  peri- 
tonitis which  is  most  severe  in  the  right  upper  quadrant,  and 
which  appears  to  have  produced  general  peritonitis.  The 
main  question  is :  what  has  perforated  ?  Presumably  the 
present  symptoms  are  due  tb  the  same  cause  as  those  which 
had  previously  confined  him  in  the  hospital  three  weeks. 
This  is  the  second  attack.  Against  Intestinal  obstruction  is 
the  marked  localization  of  the  symptoms  in  the  right  hypo- 
chondrium, and  the  age  of  the  patient.  Intestinal  obstruc- 
tion in  young  people  is  generally  due  to  the  bands  or  adhesions 
produced  by  previous  operations  or  previous  attacks  of  peri- 
tonitis. We  have  no  sufficient  evidence  that  either  of  these 
has  occurred   in   this   patient.      The  amount  of   tenderness 


122  CASE   HISTORIES    IN   MEDICINE. 

is  out  of  proportion  to  what  we  should  expect  in  pure 
obstruction. 

Between  peptic  ulcer  and  cholecystitis  the  diagnosis  is 
difficult.  On  the  whole,  however,  the  history  seems  to  me 
more  like  gall-bladder  disease  than  like  peptic  ulcer,  for  the 
attacks  of  the  latter  disease  are  apt  to  last  more  than  a  day, 
and  are  generally  accompanied  by  vomiting  whefi  they  have 
persisted  for  a  number  of  years  as  in  the  present  case.  There 
is  no  evidence  that  the  attacks  were  relieved  by  food  or  that 
any  other  method  of  relief,  such  as  soda  or  gastric  lavage,  had 
been  discovered.  On  the  whole,  then,  the  gall-bladder  seems 
more  probably  the  seat  of  the  disease.  Since  the  present  symp- 
toms, those  of  perforative  peritonitis,  it  seems  probable  that 
perforation  of  the  gall-bladder  has  taken  place.  Possibly  one 
of  the  bile-ducts  may  have  been  perforated  by  a  stone. 

Prognosis:  Since  it  appears  that  the  inflammation  has  not 
become  walled  over,  but  is  pretty  general  throughout  the 
peritoneum,  our  prognosis  must  necessarily  be  very  grave,  as 
is  always  the  case  in  general  peritonitis.  The  possibility  of  re- 
covery depends  upon  the  promptness  and  thoroughness  of  the 
surgical  interference,  the  nature  of  the  infecting  organism,  and 
the  patient's  power  of  resistance. 

Treatment:  There  is  no  justification  for  any  treatment 
except  prompt  laparotomy.  This  was  at  once  performed  in 
the  present  case,  and  showed  perforative  cholecystitis;  never- 
theless the  patient  died  the  next  day. 


DISEASES    OF   GASTROINTESTINAL   AND   BILIARY  TRACTS.     123 

Case  42.  A  cigar  maker,  fifty-one  years  of  age,  is  seen 
March  15.  Family  history  negative.  Thirty- five  years  ago 
had  tuberculosis  of  the  knee,  which  recovered  after  operation, 
but  left  a  stiff  joint.  Eighteen  years  ago  he  had  jaundice  and 
fifteen  years  ago  syphilis,  otherwise  always  well.  Has  used 
beer  to  excess. 

About  six  weeks  ago,  while  in  his  usual  health,  he  had  an 
attack  of  acute  bronchitis  for  which  he  was  given  iodid  of 
potassium.  This,  he  says,  upset  his  stomach  and  caused  vom- 
iting which  lasted  for  a  number  of  days.  About  two  weeks 
after  his  cough  began,  he  noticed  that  his  skin  had  a  yellow 
tint  which  has  been  steadily  deepening.  Coincident  with 
the  jaundice  a  circumscribed  reddish  eruption  appeared  on 
various  parts  of  his  body  and  limbs,  which  was  diagnosed  by 
his  attending  physician  as  erythema  multiforme.  Itching 
has  been  general  and  intense.  There  has  been  no  vomiting 
for  over  two  weeks,  but  his  food  has  been  carefully  regulated. 
His  appetite  is  poor.  He  has  lost  much  in  strength  and 
flesh.  His  temperature  has  remained  near  the  normal  line, 
but  has  occasionally  risen  to  100°  F.,  particularly  during  the 
last  week.  The  pulse  has  varied  between  70  and  80,  with  a 
rising  tendency.     The  stools  are  clay-colored. 

Patient  still  preserves  considerable  fat  tissue,  but  has  evi- 
dently lost  weight  and  looks  sick.  Deep  icterus  of  a  de- 
cidedly greenish  tinge.  Heart  and  lungs  normal.  The  liver 
dulness  begins  at  the  sixth  rib.  Its  lower  edge,  which  appears 
to  be  smooth,  can  be  felt  about  an  inch  below  the  costal 
margin.  A  fluctuating  tumor  of  indefinite  outline  and  size 
is  suspected  below  the  hepatic  edge  about  in  the  mammillary 
line.  Percussion  over  it  shows  an  area  of  dulness  about  two 
inches  in  diameter.  Deep  palpation  of  abdomen  reveals  no 
other  abnormality.  No  glandular  enlargement,  no  charac- 
teristic scars.  Urine  contains  much  bile,  but  no  other  ab- 
normal constituents.     White  cells  8000. 

1.  What  points  in  the  past  history  are  most  important  here? 

The  syphilis  and  the  alcoholism. 

2.  What  diseases  produce  the  deepest  icterus?     Gall-stones 

and  cancer  of  the  bile  ducts  or  the  pancreas. 

3.  (a)  What  is  the  tumor?  and   (6)  what  is  its  connection 


124  CASE   HISTORIES   IN   MEDICINE. 

(if  any)  with  the  eruption  and  the  itching  ?  (a)  Prob- 
ably the  gall-bladder,  (b)  None.  The  eruption  is  due 
either  to  KI  or  to  syphilis  (see  below),  and  the  itching 
to  jaundice. 

4.  Do  you   expect  pain  in  this  case?     Why,   or  why  not? 

Probably  not,  because  there  is  probably  no  disease 
present  which  stretches  the  liver's  capsule. 

5.  What  explains  the  fever  ?     Syphilis  and  cancer  both  cause 

fever  (see  below). 

6.  Are  any  important  data  missing?     The  condition  of  the 

chest,  the  size  of  the  spleen,  evidence  for  or  against 
ascites. 

Diagnosis:  Syphilis  of  the  liver,  cirrhosis,  gall-stones,  and 
cancer  are  to  be  considered.  Cirrhosis  cannot  be  diagnosed 
in  the  absence  (as  here)  of  any  evidence  of  portal  stasis.  It 
cannot  be  positively  excluded,  but  does  not  account  for  all 
the  facts  in  the  case.  Gall-stones  are  rarely  associated  with 
both  jaundice  and  palpable  gall-bladder.  (The  tumor  in  the 
gall-bladder  region  is  probably  thus  to  be  explained.)  Syph- 
ilis can  only  be  excluded  by  the  therapeutic  test,  but  it 
rarely  produces  jaundice  or  enlarged  gall-bladder.  Cancer  of 
the  pancreas  is  the  commonest  cause  of  the  group  of  symp- 
toms here  present;  the  common  bile-duct  is  pressed  upon  by 
the  tumor,  and  intense  jaundice  with  dilated  gall-bladder 
results. 

Prognosis:  Cases  of  true  cancer  of  the  pancreas  usually 
prove  fatal  within  nine  months  of  the  time  when  the  symp- 
toms are  sufficiently  advanced  to  permit  of  diagnosis.  Errors 
and  uncertainties,  however,  are  frequent  owing  to  the  diffi- 
culty of  distinguishing  cancer  of  the  pancreas  from  chronic 
pancreatitis,  even  when  the  abdomen  is  open  and  the  pan- 
creas in  the  surgeon's  hand.  This  mistake  is  very  frequently 
made.  Hence  the  not  infrequent  "recoveries"  from  sup- 
posed pancreatic  cancer. 

Treatment:  If  the  diagnosis  Is  correct,  no  treatment  is  of 
any  value,  but  since  diagnosis  is  so  frequently  erroneous,  it 
seems  to  me  that  exploratory  laparotomy  should  be  per- 
formed in  every  case  in  which  the  patient's  condition  warrants 
his  undergoing  the  strain  of  anaesthesia  and  operative  shock. 


DISEASES    OF   GASTRO-INTESTINAL   AND    BILIARY   TRACTS.     I25 

Case  43.  A  saleswoman,  single,  thirty  years  old,  is  seen 
April  23.  Her  mother  died  of  cancer  of  the  uterus.  She 
had  chorea  at  twelve,  and  has  since  had  frequent  attacks  of 
rheumatism;  has  never  been  strong;  is  of  constipated  habit. 
Catamenia  regular.  On  April  3  she  had  rheumatic  pain 
and  swelling  in  several  of  her  joints  which  kept  her  in  bed 
for  three  days.  She  then  started  to  work  again,  but  on  the 
following  day,  April  7,  she  began  to  complain  of  nausea  and 
felt  slightly  feverish.  The  next  morning  she  felt  "  dread- 
fully; "  was  very  weak  and  feverish.  She  was  nauseated,  but 
unable  to  vomit.  Her  temperature  was  somewhat  elevated 
for  the  first  three  days.  Jaundice  and  clay-colored  stools 
were  first  noticed  on  April  9.  Her  chief  complaints  have 
been  weakness,  constipation,  nausea,  and  vomiting.  All  food 
has  caused  gastric  distress,  so  that  she  has  eaten  very  little 
of  the  fat  free  diet  which  was  allowed  her. 

Patient  is  markedly  emaciated  and  jaundiced.  The  heart's 
apex  is  in  the  fifth  interspace,  one  inch  to  the  left  of  the 
nipple  line.  Its  right  edge  is  one  inch  outside  of  the  right 
border  of  the  sternum.  A  soft  systolic  murmur  is  heard 
at  the  apex  transmitted  to  the  axilla.  The  second  pulmonic 
sound  is  accentuated.  The  abdomen  is  soft,  lax,  and  tym- 
panitic. The  upper  border  of  the  liver  is  at  the  fifth  inter- 
costal space.  Its  sharp,  smooth  edge  can  be  felt  below  the 
costal  margin.  It  was  somewhat  tender  on  pressure  up  to  a 
few  days  ago.  Physical  examination  is  otherwise  negative. 
Urine  acid,  high-colored,  specific  gravity  1025,  very  slight 
trace  of  albumin.  Bile  pigment  present.  Sediment  contains 
occasional  hyalin  and  fine  granular  casts.  Stools  are  clay- 
colored.     Temperature  98°,  pulse  60,  respiration  18. 

Diagnosis:  Apparently  this  patient's  trouble  started  out 
with  a  multiple  arthritis,  in  other  words,  with  evidence  of  an 
infectious  disease,  but  this  particular  manifestation  has  now 
disappeared  and  we  have  to  deal  with  a  case  of  jaundice  with 
emaciation  and  a  somewhat  enlarged  liver,  the  symptoms  of 
approximately  three  weeks'  duration  occurring  in  a  young 
unmarried  woman.  In  such  cases  catarrhal  jaundice  is  our 
natural  diagnosis  provided  we  can  exclude  gall-stones  and 
cancer.     The  age  of  the  patient,  the  absence  of  severe  pain 


126  CASE   HISTORIES   IN   MEDICINE. 

or  enlargement  of  the  gall-bladder,  makes  it  impossible  for 
us  to  call  the  trouble  gall-stones,  though  that  disease  cannot 
be  definitely  excluded.  Cancer  is  likewise  very  unusual  at 
this  patient's  age  and  we  have  no  positive  evidence  in  its 
favor.  It  seems  reasonable  therefore  to  base  our  prognosis 
and  treatment  upon  the  belief  that  the  patient  is  suffering 
from  that  form  of  acute  infection  which  results  in  jaundice 
of  the  type  ordinarily  called  catarrhal.  In  my  opinion  this 
is  the  nature  of  the  vast  majority  of  cases  of  catarrhal  jaun- 
dice. There  is  very  little  evidence  to  support  the  old  theory 
of  a  gastric  catarrh  extending  to  the  duodenum  and  up  the 
common  bile-duct  so  as  to  occlude  the  latter. 

Prognosis:  In  the  vast  majority  of  cases  the  patient  is 
free  from  symptoms  within  six  weeks  of  the  beginning  of  the 
illness.  Any  extension  of  symptoms  beyond  this  time  makes 
the  diagnosis  doubtful.  Attacks  occasionally  recur,  but  this 
is  infrequent.  The  greater  number  of  cases  get  well  within 
three  weeks  though  the  coloration  of  the  eyes  may  persist 
somewhat  longer. 

Treatment:  To  make  the  patient  comfortable  is  all  that 
we  can  do.  We  have  no  medicines  or  other  agents  which 
will  accelerate  the  disappearance  of  the  jaundice  or  force  the 
bile  to  flow  more  freely.  The  use  of  the  so-called  cholagogues 
and  of  ox-bile  is  altogether  without  benefit  in  my  hands,  and 
we  have  no  reason  for  being  disappointed  at  this  result. 
Calomel  has  no  special  value  although  it  is  of  course  desir- 
able to  use  whatever  methods  may  be  necessary  to  keep  the 
bowels  free. 

The  patient  should  be  given  a  diet  adjusted  to  his  powers 
of  digestion,  but  what  these  powers  are  has  to  be  ascertained 
by  experiments  in  each  case.  In  my  experience  fats  and 
carbohydrates  are  borne  fully  as  well  as  proteids. 


DISEASES    OF   GASTRO-INTESTINAL   AND   BILIARY   TRACTS.     12/ 

Case  44.  A  vigorous  man  of  sixty-two  comes  of  a  gouty 
family,  many  members  of  which  have  been  long-Uved.  His 
mother  is  said  to  have  died  of  cancer,  seat  unknown;  and  a 
paternal  uncle  of  gastric  cancer.  In  recent  years  the  patient 
had  had  two  brief  attacks  of  pain  and  swelling  in  the  great 
toe-joint;  he  has  also  had  eczema,  said  to  have  been  considered 
of  gouty  origin.  For  some  years  he  has  occasionally  lost 
moderate  quantities  of  fresh  blood  from  the  rectum.  He  has 
been  a  good,  though  not  a  free  liver;  and  has  always  taken 
much  exercise  in  the  open  air. 

Six  months  ago  he  was  duck  shooting  on  Lake  Erie,  and, 
the  water  being  very  low,  he  says  that  for  three  weeks  he 
worked  harder  than  ever  before  in  his  life,  pushing  and 
dragging  his  boat  in  shallow  water.  After  returning  home 
he  felt  tired  and  was  indisposed  to  exert  himself  in  any  way. 
Soon  after  he  began  to  suffer  every  few  days  about  i  p.m. 
from  severe  continuous  pain  just  below  the  right  costal 
border  and  outside  the  edge  of  the  rectus  muscle.  The  pain 
bore  no  apparent  relation  to  the  quality  of  food;  the  attacks 
lasted  from  one-half  an  hour  to  three  hours,  and  were  relieved 
by  the  passage  of  gas  upward  or  downward.  Sometimes  the 
escape  of  gas  seemed  to  be  promoted  by  cooking  soda  or 
aromatic  spirits  of  ammonia.  The  pain  is  sometimes  very 
sharply  localized,  even  to  a  point  no  larger  than  the  finger 
tip;  but  sometimes  spreads  to  the  left  and  downw^ard  over 
an  area  as  large  as  the  palm  of  the  hand.  Gradually  the 
attacks  have  increased  in  frequency  and  come  on  daily;  of 
late,  toward  5  p.m.  There  has  been  at  times  slight  nausea 
apparently  due  to  the  extreme  severity  of  the  pain.  He 
never  vomited  until  tw^o  days  before  he  was  seen,  then 
repeatedly  during  the  night;  the  vomitus  was  not  character- 
istic. Position  does  not  seem  to  influence  the  pain  except  in 
so  far  as  it  may  aid  the  expulsion  of  gas. 

A  week  or  ten  days  before  he  was  seen,  he  had  on  two 
successive  days  black  movements  of  the  bowels,  one  very 
copious,  unattended  by  rectal  pain,  faintness,  or  subsequent 
loss  of  color.  Fever  has  been  absent,  and  the  urine  negative. 
The  appetite  and  ordinary  digestion  have  been  fair;  there 
has  been  no  noticeable  loss  of  flesh  or  color.     The  tongue  is 


128  CASE   HISTORIES   IN   MEDICINE. 

slightly  coated,  the  fingers  show  some  gouty  deposits,  there 
is  some  tenderness  on  deep  pressure  just  above  and  to  the 
right  of  the  navel;  the  smooth  edge  of  the  liver  can  be  felt 
to  descend  below  the  right  costal  border,  but  only  on  full 
inspiration.     Physical  examination  is  otherwise  negative. 

1.  What  diseases  often  cause  epigastric  pain  relieved  by  the 

belching  of  gas?  Dyspepsia  of  various  types,  angina 
pectoris,  neurasthenia.  Usually  motor  disturbance  and 
not  fermentation  is  the  cause  of  such  belching. 

2.  What  type  of  stomach  trouble  is  to  be  expected  at  the 

age  of  sixty- two?  Cancer;  rarely  ulcer;  sometimes  the 
gastric  symptoms  depending  on  gall-stones,  cardiac  dis- 
eases and  their  results. 

3.  What  is  the  relation  of  the  gout  to  the  other  symptoms? 

Gout  and  arteriosclerosis  are  often  closely  associated. 
Arteriosclerosis  is  one  of  the  diagnoses  to  be  considered 
in  this  case. 

Diagnosis:  Duodenal  ulcer  is  strongly  suggested  by  the 
position  and  sharp  localization  of  a  pain  which  tends  to  occur 
when  the  stomach  is  empty,  by  the  tarry  stools  and  the  relief 
by  alkalis.  Hepatic  cirrhosis  is  possible,  but  rarely  causes 
such  pain  and  cannot  be  diagnosed  unless  evidence  of  portal 
stasis  appears.  Angina  pectoris  may  cause  abdominal  pain 
relieved  by  belching,  but  never  produces  melaena.  There  are 
no  physical  evidences  of  arteriosclerosis,  but  it  may  never- 
theless be  present.  On  the  whole,  the  chief  symptoms  in  the 
case  seem  best  explained  by  the  diagnosis  of  duodenal  ulcer. 
The  course  of  the  case  apparently  confirmed  this  diagnosis. 

Prognosis  and  Treatment  :  (see  Case  6). 


DISEASES    OF   GASTROINTESTINAL   AND    BILIARY   TRACTS.     1 29 

Case  45.  J.  S.,  aged  forty  years,  a  merchant,  was  seen  in 
consultation  April  8  at  lO  P.M. 

He  had  suffered  for  years  with  indigestion,  and  had  lost 
considerably  in  weight.  For  several  months  he  had  been 
treated  by  an  eminent  specialist  in  diseases  of  the  stomach. 
His  stomach  had  been  washed  out  for  three  weeks.  He  had 
been  on  a  liquid  diet.  He  had  made  no  improvement  and 
for  one  week  had  remained  in  bed  on  account  of  an  aggrava- 
tion of  epigastric  pain.  At  one  o'clock  on  the  8th  of  April 
he  got  out  of  bed  and  went  to  the  back  door  to  look  out. 
While  there  he  was  seized  with  sudden  severe  pain  in  the 
abdomen.  He  vomited  and  crawled  back  to  bed.  His 
attending  physician  saw  him  at  3  p.m.  He  found  his  pulse 
90,  temperature  101°,  abdomen  of  boardlike  rigidity,  tender 
everywhere,  but  much  more  tender  in  the  epigastrium.  The 
patient  showed  but  little  shock.  His  physician  administered 
I  grain  of  morphin  and  saw  him  again  at  9  p.m.  He  was 
then  somewhat  improved,  and  his  spasm  was  a  little  less. 
The  consultant  saw  him  at  11  p.m.,  and  found  him  pale, 
sick-looking,  with  no  peritoneal  facies  and  no  marked  shock. 
There  was  distinct  spasm  and  tenderness  In  the  epigastrium, 
shading  off  into  other  regions  of  the  abdomen,  which  was 
generally  retracted.  There  was  no  dulness.  The  tongue  was 
moist.     Pulse  90,  temperature  101.4°. 

1.  What  is  the  significance  of  the  peritoneal  facies  and  why 

was  it  absent  in  this  case  ?  Vomiting,  fear,  or  both  are 
the  usual  causes  of  the  peritoneal  facies,  which  is  often 
seen  in  simple  seasickness.  The  absence  of  "  shock  " 
or  of  recent  vomiting  explains  the  absence  of  this 
"  peritoneal  facies." 

2.  In  what  diseases  is  the  use  of  the  stomach  tube  contra- 

indicated  ?  When  aneurism  or  bleeding  gastric  ulcer  is 
suspected,  or  in  very  weak  patients. 

3.  What  further  data  might  be  of  value  in  diagnosis  here? 

Blood  examination,  urinary  examination,  color  of  con- 
junctivae (see  also  next  question). 

4.  How  can  we  exclude  plumbism  ?     By  careful  questioning, 

examination  of  the  gums,  blood,  and  extensor  muscles 
(wrist  drop).  Tabes  dorsalis?  By  testing  pupils  and 
knee-jerks.  Malaria?  Search  for  parasites  and  en- 
larged spleen. 


130  CASE   HISTORIES   IN   MEDICINE. 

Diagnosis :  Lead,  tabes,  and  malaria  were  excluded ;  lapar- 
otomy showed  a  perforated  gastric  ulcer  (anterior  gastric 
surface)  walled  off  by  fresh  adhesions.  Posterior  gastro- 
enterostomy was  done.  Three  months  later  the  patient  had 
gained  markedly  in  weight  and  was  in  excellent  condition. 
Acute  cholecystitis  and  acute  pancreatitis  were  excluded  posi- 
tively only  by  the  operation.  The  preceding  gastric  symp- 
toms suggested  the  stomach  as  the  source  of  the  trouble,  but 
are  compatible  with  pancreatitis  or  gall-bladder  trouble. 

Prognosis  and  Treatment  :  (see  Case  6) . 


DISEASES   OF   GASTRO-INTESTINAL   AND    BILIARY   TRACTS.     I3I 

Case  46.  A  Jewish  buyer  of  twenty-eight  consulted  me 
May  6,  1910,  complaining  that  immediately  after  meals  he 
feels  a  weight  in  the  region  of  the  lower  sternum.  This  sen- 
sation lasts  about  half  to  three-quarters  of  an  hour.  He  has 
noticed  it  for  seven  months,  but  it  has  been  especially  trouble- 
some for  the  past  two  months.  He  is  also  conscious  of  a  sense 
of  continual  irritation  about  the  navel  and  says  that  while 
at  stool  he  has  a  horrible  feeling  of  emptiness  in  the  lower 
part  of  his  abdomen.  He  has  no  nausea  or  vomiting,  his 
appetite  is  excellent,  and  in  other  ways  he  feels  well.  At  the 
age  of  sixteen  he  weighed  140.  For  the  past  two  years  he 
has  weighed  270. 

Physical  examination  showed  nothing  but  extreme  obesity. 

1.  What  are  the  common  causes  of  substernal  pain  without 

external  manifestations  ?  Angina  pectoris,  general  ner- 
vous fatigue,  and  flatulence  with  or  without  gastric 
stasis  and  fermentation.  Aneurism  and  mediastinal 
tumors  occasionally  give  pain  In  this  region,  but  as  a 
rule  the  suffering  which  they  cause  is  referred  to  the 
region  of  the  manubrium  and  the  adjoining  parts  of  the 
upper  chest. 

2.  Significance  of  pain  immediately  after  meals?     Until  the 

last  decade  such  pain  was  usually  considered  suspicious 
of  peptic  ulcer,  but  the  surgical  experience  of  the  last 
ten  years  seems  to  show  that  gastric  or  duodenal  dis- 
comfort connected  with  ulcer  Is  much  more  likely  to 
come  before  meals  or  at  any  rate  after  a  considerable 
Interval  following  the  taking  of  food.  In  other  words. 
It  seems  to  be  relieved  rather  than  produced  by  eating. 
Post-prandial  pain  is  more  apt  to  be  due  to  chlorosis, 
pulmonary  tuberculosis,  gall-stones,  nervous  dyspepsia, 
or  gastric  stasis  however  produced. 

Diagnosis  and  Treatment :  The  essential  point  appeared  to 
me  to  be  the  enormous  gain  in  weight.  On  cross-questioning, 
the  patient  admitted  that  his  appetite  was  enormous,  and 
volunteered  the  remark  that  he  thought  he  often  ate  too 
much.  In  view  of  the  history  and  the  results  of  the  physical 
examination  the  case  seemed  to  me  one  of  simple  overeating, 
to  be  relieved,  in  all  probability,  by  a  modification  of  this 
habit. 


132  CASE  HISTORIES   IN  MEDICINE. 

Prognosis:  In  most  cases  the  patient  finds  the  cure  worse 
than  the  disease  and  does  not  change  his  habits.  If  he  ever 
comes  to  prefer  comfort  to  gluttony  he  can  usually  cure 
himself  in  a  few  months  or  less. 


DISEASES    OF   GASTRO-INTESTINAL   AND   BILIARY   TRACTS.     1 33 

Case  47.  p.  J.  G.,  twenty  years  old,  a  piano  varnisher, 
was  admitted  to  the  hospital  October  3,  1903.  For  about  a 
year  he  had  suffered  from  occasional  pain  in  the  epigastrium, 
and  for  six  months  had  always  had  pain  after  taking  food. 
One  week  ago,  he  received  a  blow  in  the  right  hypochondrium 
while  boxing,  and  after  that  had  slight  pain  in  that  region 
until  the  day  before  entrance,  when  he  was  taken  suddenly 
ill  with  violent,  griping  pain,  starting  in  the  epigastrium  and 
spreading  all  over  the  abdomen.  His  bowels  had  not  moved 
since  this  pain  started.  He  vomited  after  taking  warm  drinks, 
and  had  a  chill  lasting  one  hour.  He  walked  to  the  out- 
patient department,  where  his  temperature  was  found  to  be 
100.3°,  pulse  60.  His  skin  was  slightly  yellow.  The  abdo- 
men showed  no  distention.  There  was  slight  general  spasm 
and  tenderness  over  the  gall-bladder  region.  No  mass  could 
be  felt.     The  leucocyte  count  was  16,000. 

With  rest  in  bed  and  emptying  of  the  bowels  by  enemata, 
the  tenderness  and  spasm  over  the  gall-bladder  region  dis- 
appeared until  on  October  7  there  were  very  few  symptoms 
left. 

Diagnosis:  The  symptoms  are  those  of  acute  localized 
peritonitis.  Other  causes  of  epigastric  pain  (such  as  plum- 
bism,  tabes,  and  uraemia)  are  excluded  by  the  tenderness  and 
spasm.  Localized  peritonitis  in  a  man  of  twenty  is  oftenest 
caused  by  appendicitis,  cholecystitis,  and  peptic  ulcer.  Pan- 
creatitis, intestinal  obstruction,  and  floating  kidney  are  rare 
causes,  especially  in  a  young  man.  Acute  gastro-enteritis 
usually  produces  diarrhoea  and  has  less  tenderness  and  spasm. 

Between  appendicitis,  cholecystitis,  and  peptic  ulcer  the 
following  considerations  should  be  weighed.  Cholecystitis  is 
not  common  under  twenty-five;  nevertheless  the  site  of  the 
physical  signs  in  this  case  corresponds  accurately  with  that 
of  the  gall-bladder.  Peptic  ulcer  is  faintly  suggested  by  the 
history  of  gastric  troubles  here.  Appendicitis  usually  produces 
signs  lower  down  in  the  abdomen.  The  constitutional  symp- 
toms of  the  case  are  consistent  with  any  of  the  three  diagnoses 
considered. 

An  operation  for  gall-stones  was  done,  but  the  gall-bladder 
and  appendix  were  found  normal.     There  was  an  excess  of 


134  CASE   HISTORIES   IN   MEDICINE. 

clear,  dark,  peritoneal  fluid  and  a  perforation  of  the  stomach 
near  the  pyloric  end,  which  was  glued  to  the  under  surface  of 
the  liver  by  fresh  adhesions. 
Prognosis  and  Treatment  :  (see  Case  6). 


DISEASES   OF   GASTRQ-INTESTINAL   AND    BILIARY    TRACTS.      1 35 

Case  48.  A  coachman  of  forty-five,  of  a  very  neurotic 
family,  has  had  dyspepsia  for  fifteen  years.  Any  worry  or  ex- 
citement brings  on  distress  and  sour  eructations.  Three  years 
ago  had  "  spinal  meningitis;"  since  then  never  well  in  mind 
or  body.  Forgetful  and  bewildered  up  to  the  last  two  months, 
when  he  became  much  clearer  and  has  since  devoted  himself 
to  his  health.  Two  spots,  one  over  the  left  kidney  and  one 
on  the  top  of  his  skull,  feel  hot  to  him.  Also  numbness  on 
the  left  leg,  less  noticed  when  he  is  busy.  Left  hand  always 
colder  than  the  right. 

Since  the  fever  three  years  ago  his  dyspepsia  has  been 
worse.  Almost  any  food  distresses  him  after  a  time.  More 
than  one-half  a  cupful  of  any  liquid  causes  vomiting,  and  de- 
spite care  he  vomits  very  frequently.  No  blood  or  brown 
stuff  in  vomitus,  which  consists  of  food  and  slime. 

Pain  and  tenderness  in  the  epigastrium  are  almost  inces- 
sant. Appetite  excellent,  bowels  always  costive,  sleeps 
poorly. 

Examination:  Rather  thin,  good  color,  tongue  protruded 
very  far.  In  epigastrium,  a  resistance  uneven,  soft  and 
doughy  in  feel,  dull  on  percussion  and  very  tender.  The  lower 
border  of  it  is  well  defined,  especially  on  the  left.  At  times, 
movements,  apparently  peristaltic,  can  be  felt  there.  Vis- 
ceral examination  is  otherwise  negative. 

The  stomach  tube  was  passed  and  abundant  free  hydro- 
chloric acid  found,  but  the  ingestion  of  over  six  ounces  of 
liquid  caused  the  patient  great  pain,  which  lasted  for  two 
hours  after  the  tube  was  removed. 

The  patient  was  constantly  expectorating  saliva,  and 
stated  that  milk  always  poisoned  him,  and  that  the  only 
food  that  agreed  with  him  is  wild  game.  A  partridge  was 
procured  for  him,  but  he  had  a  bad  night  after  it,  because,  as 
he  said,  he  tasted  some  of  the  shot  with  which  the  partridge 
had  been  killed.  He  remained  in  the  hospital  from  Novem- 
ber I  to  November  ii,  1892,  and  then  left  unimproved. 

Diagnosis:  The  first  paragraph  and  the  last  point  very 
strongly  to  a  gastric  neurosis,  and  this  diagnosis  still  stands 
on  the  hospital  record  book  to-day.  Against  this,  however, 
are  the  small  capacity  of  the  stomach   (six  ounces  causes 


136  CASE   HISTORIES   IN   MEDICINE. 

great  pain  and  often  vomiting),  the  peristaltic  movements  in 
the  epigastrium,  and  the  other  physical  signs  at  that  point. 
A  contracted  stomach  with  pyloric  obstruction  and  abundant 
free  HCl  is  a  very  unusual  combination,  but  to  that  the  signs 
point.  At  autopsy  (three  months  later)  exactly  this  com- 
bination was  found.  The  gastric  wall  was  from  one-half  to 
three-quarters  of  an  inch  thick,  the  capacity  about  seven 
ounces,  the  scar  of  a  large  ulcer  near  the  pylorus,  and  great 
thickening  and  stenosis  of  the  latter.  The  case  is  very  im- 
portant because  both  neurasthenia  and  organic  disease  were 
present,  and  the  neurasthenic  aspects  altogether  blinded  us 
to  the  rest. 

Prognosis  and  Treatment:  An  operation  should  of  course 
have  been  done,  and  with  this  the  patient  might  well  have 
recovered  within  a  few  months  (see  also  Case  6). 


DISEASES   OF   GASTRO-INTESTINAL   AND    BILIARY   TRACTS.     1 37 

Case  49.  A  washerwoman,  sixty-eight  years  old,  gener- 
ally healthy,  has  been  feeling  poorly  for  a  month  and  losing 
appetite.  A  week  ago  began  to  have  pain  in  abdomen;  at 
first  all  over,  but  later  settling  in  the  lower  left  corner.  It 
is  worse  when  she  walks,  but  has  not  kept  her  awake  until 
last  night.  She  has  always  been  constipated,  and  the  bowels 
have  not  moved  for  two  days;  has  eaten  little  for  two  days. 

Examination:  Emaciated,  sallow,  tongue  coated,  breath 
offensive.  Temporal  arteries  stiff  and  tortuous.  Heart  dull- 
ness reaches  to  the  right  sternal  border  and  up  to  the  second 
rib.  Apex  just  below  the  fifth  rib  in  the  nipple  line.  At  the 
ensiform  cartilage,  a  short  murmur  replacing  the  second  heart 
sound  and  heard  less  distinctly  elsewhere.  First  sound  at 
the  apex  very  short;  heart's  action  somewhat  irregular.  Few 
moist  rales  at  bases  of  both  lungs,  with  slight  dulness  and 
diminished  breathing  over  lower  half  of  left  back;  voice  sounds 
normal,  tactile  fremitus  diminished.  Abdomen  slightly  dis- 
tended; tender  in  left  iliac  fossa,  where  a  deep  resistance  is 
felt,  but  no  tumor.  Liver  dulness  from  seventh  rib  to  rib 
margin.  Right  kidney  palpable.  Urine  normal  color,  acid 
1017,  trace  of  albumin,  no  sugar.  Sediment:  pus,  squamous, 
and  spindle  cells,  calcic  oxalate  and  mucus.  Knee-jerks  not 
obtained.  Temperature  102°  at  entrance  to  the  hospital, 
normal  next  day.  Pulse  100.  An  enema  brought  away  a 
small  movement,  very  dark  in  color. 

1,  What  is  the  significance  of  tortuous  temporal  arteries? 

Nothing,  unless  they  are  also  rough  and  hard.  All 
temporal  arteries  are  tortuous. 

2.  How  do   you  interpret  the  dimensions  of  the  heart  in 

this  case?     They  are  normal, 

3,  How  do  you  explain  the  murmur?     If  the  pulse  is  col- 

lapsing the  murmur  is  probably  due  to  aortic  regurgi- 
tation, 

4.  How  does  the  significance  of  arhythmia  in  aortic  regurgi- 

tation differ  from  its  significance  in  mitral  stenosis  ? 
It  is  much  more  serious  in  aortic  disease.  Mitral 
arhythmia  is  consistent  with  years  of  fair  health. 

5.  Name    three    common    causes    of    cardiac    arhythmia. 

Myocardial  weakness,  mitral  disease,  tobacco, 

6,  What  sort  of  pulse  should  you  expect  in  this  case?     A 

collapsing  pulse. 


138  CASE   HISTORIES   IN   MEDICINE. 

7.  How  much   can  be  inferred  from   the  pulmonary  signs 

here  described  ?     CEdema  of  the  lungs  with  right  hydro- 
thorax. 

8.  How  do  you  explain  the  area  of  liver  dulness  here  given  ? 

Senile  emphysema. 

9.  What  does  the  calcic  oxalate  mean  here  ?     Nothing  — 

as  is  usually  the  case. 
10.    How  is  the  temperature  accounted  for?     The  fatigue  and 
emotion  strain  of  entering  the  hospital. 

Diagnosis:  A  high  enema  brought  away  an  enormous 
amount  of  feces  with  great  relief  to  all  symptoms.  Fecal 
impaction  and  arteriosclerosis  seemed  to  account  for  all  the 
facts  in  her  case.  Sigmoid  cancer  was  excluded  by  the  course 
of  the  case. 

Prognosis  and  Treatment:  By  regular  enemata  the  recur- 
rence of  impaction  can  probably  be  prevented. 


DISEASES   OF   GASTRO-INTESTINAL  AND    BILIARY   TRACTS.     1 39 

Case  50.  Mrs.  A.,  a  Jewess  of  thirty-six,  has  been  suffer- 
ing for  six  months  with  pain  in  her  left  side.  At  the  begin- 
ning of  the  period  a  small  lump  appeared  in  the  left  breast. 
It  was  pronounced  cancer  by  a  competent  surgeon  and  im- 
mediate removal  was  advised,  but  in  three  days  it  had  com- 
pletely disappeared  and  has  not  been  seen  since.  From  that 
time  to  the  present  she  has  had  pain  of  gradually  increasing 
severity  throughout  the  left  side  of  her  body  and  in  the  back 
of  the  head.  When  the  attacks  of  pain  come  she  feels  flushed 
but  looks  pale  (sometimes  with  red  spots  on  the  face),  and 
has  "  electric  feelings  "  in  the  chest  which  are  somewhat 
relieved  (as  is  the  pain)  by  pressure  with  the  hand. 

The  pain  is  most  apt  to  come  on  at  night  and  sometimes 
keeps  her  awake  or  checks  speech.  There  is  a  constant  sense 
of  pressure  at  the  root  of  the  nose  and  a  beating  in  the  head. 

Her  appetite  is  poor  and  there  is  often  "  bloating  "  after 
meals.     The  bowels  are  costive  and  she  is  nervous. 

In  the  past  three  months,  since  a  vacation  in  the  country, 
with  a  good  deal  of  exercise,  she  has  decidedly  improved,  and 
now  has  the  pain  not  more  than  an  hour  or  two  a  day.  The 
day  after  a  good  night  sweat  (which  she  has  occasionally) 
she  feels  much  better.  She  thinks  she  has  lost  about  six 
pounds  in  weight. 

Physical  examination  (including  blood  and  urine)  is  nega- 
tive. 

Diagnosis:  The  dictum  of  the  competent  surgeon  had  im- 
pressed itself  with  such  force  upon  the  mind  of  this  neurotic 
Jewess  that  she  could  not  rid  herself  of  the  idea  of  cancer 
somewhere,  internal  if  not  external.  The  wide  area  over 
which  pain  is  felt  (head,  chest,  leg),  the  vasomotor  symptoms 
and  parsesthesia,  the  relief  by  vacation  in  the  country  with 
relatively  good  hygiene,  and  the  improvement  after  sweating 
all  point  to  di  fear -neurosis  as  the  chief  cause  of  her  symptoms. 
No  doubt  the  constipation  and  dyspepsia  play  a  considerable 
part  in  her  sufferings.  Of  course  the  negative  results  of 
physical  examination  are  most  important  as  confirmatory 
evidence  of  the  neurotic  basis  of  the  symptoms. 

Prognosis:  I  have  called  the  diagnosis  of  this  case  "  appre- 
hension," with  "constipation"   as  a   minor  element  in   the 


140  CASE   HISTORIES   IN   MEDICINE. 

illness.  The  outlook  for  a  neurosis  of  this  type  depends,  in 
the  first  place,  upon  the  degree  of  intelligence  possessed  by 
the  patient.  Many  patients  cannot  be  made  to  grasp  the 
idea  that  fear  and  worry  can  so  aggravate  and  prolong  suffer- 
ings, in  themselves  trifling,  that  the  bulk  of  the  illness  may 
truly  be  said  to  be  of  psychical  origin.  If  we  cannot  get  this 
Idea  into  the  patient's  mind  by  any  direct  method,  his  chances 
of  recovery  will  depend  on  his  being  able  to  receive  some 
partial  and  debased  form  of  the  same  notion  through  a  quack 
—  an  herb  physician,  a  Christian  Scientist,  or  some  other 
misguided  person. 

Further  than  this  the  prognosis  depends  on  how  much  the 
patient  wants  to  get  well.  It  is  a  strenuous  and  difficult 
process  to  change  one's  point  of  view  and  many  a  patient 
after  getting  near  enough  to  see  what  kind  of  effort  it  means 
sidles  away  from  the  attempt  usually  in  complete  unconscious- 
ness of  what  he  is  doing.  At  bottom,  such  a  patient  would 
rather  continue  to  be  sick  than  suffer  the  pain  inseparable 
from  the  effort  which  is  necessary  for  recovery. 

A  favorable  issue  depends,  further,  upon  the  patient's 
opportunity  of  being  cared  for  by  a  physician  who  is  familiar 
with  such  troubles  and  understands  something  of  their  man- 
agement. If  a  patient  falls  into  the  hands  of  a  practitioner 
whose  only  idea  of  the  treatment  of  neurotic  conditions  con- 
sists in  prescribing  rest  and  bromid  or  sanatorium  treat- 
ment, there  is  little  to  be  hoped.  Still  worse  is  the  prospect 
for  patients  who  are  so  unfortunate  as  to  be  treated  by 
physicians  of  unrestrained  surgical  enthusiasm.  Under  these 
conditions  the  patient  may  lose  organ  after  organ  and  be 
stitched  and  patched  ad  libitum,  the  total  result,  as  a  rule, 
being  the  accentuation  of  the  existing  morbid  tendency  to 
dwell  upon  local  ills. 

It  must  further  be  admitted  that  the  prognosis  is  often 
much  better  for  the  rich  than  for  the  poor.  A  large  part  of 
what  ought  to  be  done  for  neurotic  patients  is  expensive  and, 
under  the  conditions  existing  in  most  communities,  impossible 
except  for  the  well-to-do. 

Inheritance  decidedly  influences  the  prognosis.  The  pa- 
tient, one  or  both  of  whose  parents  are  failures,  starts  with 


DISEASES   OF   GASTRO-INTESTINAL   AND    BILIARY   TRACTS.     I4I 

a  heavy  handicap.  If,  on  the  other  hand,  we  can  truly  accuse 
the  patient's  circumstances  or  his  peculiar  misfortunes  of 
having  produced  or  very  greatly  increased  his  sufferings,  the 
outlook  is  proportionately  more  cheerful. 

Treatment:  The  first  essential  is  a  thorough  physical  ex- 
amination —  essential  both  for  the  confidence  which  it  gives 
to  the  physician,  and  for  the  reassurance  which  it  produces 
in  the  patient.  In  many  cases  no  further  treatment  is  neces- 
sary after  we  have  been  able  to  assure  the  patient,  with  the 
confidence  and  authority  produced  by  such  an  examination, 
that  no  organic  disease  stands  as  an  obstacle  between  him  and 
recovery. 

The  next  step  in  treatment  Is  to  get  the  patient's  mind 
emptied,  so  far  as  possible,  of  its  accumulation  of  haunting 
fears,  doubts,  and  suspicions.  Merely  the  detailed  recital  of 
these  in  the  presence  of  a  sympathetic  listener  Is  sometimes 
a  source  of  considerable  relief.  It  also  gives  the  physician 
the  first  instalment  of  that  thoroughgoing  understanding  of 
the  patient  on  which  all  his  future  treatment  must  be  based. 
As  the  child's  nightmare  loses  much  of  its  terror  when  recited 
to  its  mother,  so  merely  the  statement  of  what  he  has  been 
through  helps  the  patient  out  of  many  of  the  simpler  troubles. 
Doubtless  the  Roman  Catholic  institution  of  the  Confessional 
has  helped  to  prevent  or  to  assuage  many  a  neurosis. 

The  next  step  is  to  explain,  as  frankly  and  fully  as  possible 
to  the  patient,  how  his  symptoms  have  been  produced  and 
aggravated  by  his  own  mental  habits  or  lack  of  habits.  He 
is  thus  enlisted  as  the  physician's  best  ally  in  combating  the 
disease. 

For  a  person  whose  life  has  lacked  routine  and  regularity, 
much  rest  and  relief  may  be  obtained  by  prescribing  a  fixed 
regimen  with  a  schedule  which  states  what  is  to  be  done  every 
hour  of  the  twenty-four.  As  a  part  of  this  regimen  every 
patient  not  already  occupied  should  be  put  to  work,  not  merely 
on  account  of  the  benefit  which  accrues  from  anything  which 
is  regular,  but  chiefly  because  work  takes  our  minds  off  our- 
selves and  gives  us  in  time  that  sense  of  being  of  some  worth 
in  the  world  which  Is  the  only  lasting  source  of  encouragement. 

As  a  rule  we  have  to  understand  something  of  the  patient's 


142  CASE   HISTORIES   IN   MEDICINE. 

home  surroundings  and  family  ties  if  we  are  to  help  him. 
The  family  must  take  its  part  in  carrying  out  the  treatment. 
Sometimes  one  or  more  of  them  needs  as  much  attention  and 
as  much  reformation  as  the  patient  himself. 

Rest  cures  are  of  value  only  as  a  preparatory  and  subordi- 
nate part  of  that  reeducation  which  is  the  essential  thing  in 
the  treatment.  If  the  patient  is  really  tired  out  by  some 
unusual  exertion  of  body  or  mind,  he  should  be  rested  as  any 
other  patient  should,  in  order  that  he  may  get  a  fair  start  upon 
that  strenuous  course  of  effort  by  which  he  may  lift  himself 
out  of  his  troubles. 

Drugs,  and  more  especially  hypnotics,  are  not  only  useless 
but  very  definitely  harmful  in  most  cases.  Of  course  they 
may  be  used  for  any  of  the  infectious  or  other  organic  com- 
plications to  which  the  neurotic,  like  other  people,  is  exposed. 
Massage,  hydrotherapy,  electricity,  and  other  physical  agents 
are  of  value  only  by  way  of  filling  up  the  patient's  unoccupied 
time  or  as  a  means  through  which  the  operator's  personality 
may  be  of  benefit  to  the  sufferer.  In  this  way  I  have  known 
osteopathy  to  prove  a  useful  vehicle  for  the  influence  of  a 
person  of  strong  character. 


CHAPTER  III. 

DISEASES    OF   THE    URINARY   TRACT. 

Case  51.  A  mill  treasurer  of  sixty-five,  always  previously 
well,  was  taken  3I  weeks  ago  with  fever  and  general  malaise. 
His  bowels  were  constipated,  his  urine  scanty,  frequent,  and 
painful.  Two  days  later  he  felt  better  and  went  to  his  office 
again  but  felt  worse  that  evening  and  called  the  doctor,  under 
whose  care  he  remained  for  the  next  week,  running  a  con- 
tinuous fever  which  was  suspected  at  the  time  to  be  typhoid, 
as  no  local  lesion  sufficient  to  account  for  it  was  discovered. 
In  the  course  of  the  next  fortnight  he  gradually  improved, 
the  fever  left  him,  and  he  was  able,  four  days  ago,  to  move 
from  his  country  place  to  his  permanent  headquarters  in 
Boston,  expecting  to  resume  work  within  a  few  days.  Three 
days  ago  he  again  noticed  fever  at  night,  although  in  the 
morning  he  seemed  to  be  free  from  it.  For  the  last  day  or 
two  he  has  noticed  that  his  urine  is  bloody,  ftut  there  is  no 
pain  either  before,  after,  or  during  its  passage.  At  present 
his  only  complaints  are  of  weakness  and  anorexia. 

On  examination  the  temperature  was  found  to  be  101°  at 
6  P.M.  Physical  examination  was  entirely  negative.  He 
was  unable  at  this  time  to  pass  any  urine.  Next  day  at  noon 
the  temperature  was  99.6°,  pulse  78.  He  felt  much  better. 
He  passed  urine  four  times  during  the  night  and  again  noticed 
that  it  was  bloody.  He  had  no  pain  and  was  eating  better. 
The  twenty-fourth-hour  urine  obtained  next  day  was  exceed- 
ingly bloody,  24  ounces  in  quantity,  specific  gravity  loio,  a 
moderate  trace  of  albumin  sufficiently  accounted  for  by  the 
amount  of  blood,  which  was  practically  the  only  unusual 
feature  of  the  sediment. 

The  prostate  showed  a  moderate  enlargement,  not  otherwise 
remarkable. 

143 


144  CASE  HISTORIES   IN  MEDICINE. 

1.  What  types  of  hsematuria  should  here  be  considered  as 

possible  causes  for  this  patient's  illness?  Since  pain  is 
absent  we  have  no  considerable  reason  to  suspect  stone 
in  the  kidney  or  bladder.  Renal  tuberculosis  is  rare  at 
his  age  and  haematuria  is  generally  less  prominent  in 
that  disease  than  bladder  symptoms  and  pyuria.  We 
have  left  neoplasms  of  the  bladder,  benign  or  malignant, 
inflammation  of  a  hypertrophied  prostate,  and  haemor- 
rhage from  a  contracted  kidney. 

2.  What  inferences  are  to  be  drawn  from  the  early  onset  of 

fever  and  from  its  recurrence  with  the  hsematuria? 
These  facts  make  prostatic  inflammation  far  more  likely 
than  either  neoolasms  or  renal  haemorrhage  complicating 
nephritis. 

Diagnosis  and  Prognosis:  Prostatic  inflammation  is  accord- 
ingly the  most  probable  diagnosis.  It  will  be  confirmed  in  case 
the  trouble  soon  quiets  down  under  appropriate  treatment  and 
no  other  symptoms  of  malignant  disease  are  manifested.  The 
prognosis  is  that  of  prostatic  hypertrophy,  the  course  of  which 
is  not  notably  modified  by  such  a  haemorrhagic  inflammation 
as  that  described  above.  In  the  present  case  the  symptoms 
were  gone  within  ten  days. 

Treatment:  Rest  in  bed,  an  abundance  of  water  by  mouth, 
and  urotropin  5  grains  three  times  a  day  were  advised  and 
proved  immediately  efficacious. 


DISEASES   OF  THE   URINARY   TRACT.  1 45 

Case  52.  A  woman  of  thirty-five,  married  ten  years,  five 
children.  Has  had  considerable  womb  trouble  and  been 
treated  for  it  by  local  physician.  Of  late,  it  has  been  less 
troublesome.  Father  died  of  cancer,  mother  of  "  a  decline." 
For  a  year  has  had  much  to  worry  her,  and  has  been  running 
down  and  getting  nervous.  Is  troubled  with  sour  eructations 
after  meals,  especially  in  the  morning.  Bowels  rather  costive. 
Appetite  as  good  as  usual.  Lost  no  fiesh.  Occasional  severe 
headache,  frontal  and  occipital.  Sleeps  poorly.  **Hot  flushes" 
frequent.  For  the  last  day  or  two  (since  coming  to  Boston) 
has  been  vomiting  a  good  deal  of  greenish  stuff. 

When  seen,  was  drawn  and  pinched  in  the  face  and  nau- 
seated. Complained  of  general  abdominal  pain,  but  no  tender- 
ness could  be  found,  and  physical  examination  was  negative 
except  a  sharply  accented  aortic  second  sound.  At  times  she 
was  quite  hysterical,  after  which  she  passed  a  large  amount  of 
pale  urine.  Very  nervous,  restless,  and  alarmed  about  herself. 
No  fever ;  pulse  1 10.  Complained  at  times  of  headache.  Knee- 
jerks  lively;  no  clonus.  Uterus  retrofiexed  and  bound  down 
with  adhesions. 

Diagnosis:  Increasing  nervousness  and  debility  for  a  year, 
headaches,  dyspepsia,  and  vomiting  might  all  be  explained 
as  the  common  portion  of  hysterical  women  at  this  age.  The 
association  of  headache  and  vomiting  ("  sick  headache  ") 
suggests  migraine,  and  the  condition  of  the  uterus  might  be 
thought  of  as  helping,  together  with  dyspepsia  and  constipa- 
tion, to  explain  these  headaches.  Such  was  in  fact  the  diag- 
nosis made  in  this  case,  and  thereby  a  serious  mistake  was 
made.  The  woman  died  in  three  days  of  urcemia.  The 
urine  by  some  accident  was  not  examined,  but  even  without 
that,  the  sharply  accented  aortic  second  sound  should,  at  her 
age,  have  suggested  nephritis.  At  autopsy  secondary  con- 
tracted kidneys  were  found. 

In  this  case  the  hysterical  symptoms  so  impressed  them- 
selves on  us,  that  we  neglected  a  thorough  search  for  organic 
disease.  It  is  important  to  remember  that  the  combination 
of  headache  and  vomiting  may  mean  either  a  common  "sick 
headache  "  or  a  dangerous  uraemia.  Organic  brain  disease, 
tumor,  abscess,  meningitis  are  also  possible,  but  there  were 


146  CASE   HISTORIES   IN   MEDICINE. 

no  focal  symptoms  or  choked  disk  in  this  case.  The  high 
tension  pulse,  sharp  aortic  second,  and  abundant  pale  urine 
pointed  straight  to  the  diagnosis,  had  we  not  been  blind  to 
it.  The  uterine  condition  in  this,  as  in  many  other  cases, 
produced  no  symptoms  and  had  nothing  to  do  with  the  case. 
Much  harm  is  often  done  by  treating  such  lesions  as  disease, 
instead  of  letting  them  alone. 

Prognosis:  In  this  particular  case  it  is  not  likely  that  any- 
thing could  have  been  accomplished  beyond  postponing  for 
a  few  weeks  or  months  the  inevitable  termination  of  the 
disease.  Like  icebergs,  most  of  whose  bulk  is  said  to  be  sub- 
merged and  invisible,  the  larger  part  of  a  case  of  chronic 
nephritis  is  wholly  latent  and  symptomless.  What  we  call 
the  symptoms  of  the  disease  are,  in  fact,  the  manifestations 
of  its  final  stages,  after  the  natural  compensations  and  the 
self-adjustments  of  the  body  have  broken  down.  Cases  seen 
for  the  first  time  with  symptoms  as  advanced  as  those  de- 
scribed above,  rarely  live  more  than  twelve  to  eighteen 
months. 

If  the  cardiac  weakness,  which  almost  always  is  account- 
able for  a  considerable  proportion  of  the  patient's  symptoms, 
turns  out,  after  careful  study,  to  be  the  dominating  element 
in  the  vicious  circle,  the  outlook  is  relatively  more  favorable 
than  in  cases  manifesting  chiefly  the  renal  or  toxic  side  of 
the  symptom  complex.  Cardiac  compensation  can  be  re- 
stored far  more  frequently  and  more  permanently  than  renal 
compensation. 

Patients  who  have  demonstrable  retinal  changes  represent 
the  severest  type  of  the  disease  and  rarely  live  more  than  a 
year  after  the  first  definite  breakdown. 

Of  similarly  ominous  significance  is  the  presence  of  anaemia 
which  is  presumably  of  the  hsemolytic  type,  and  points  to  a 
severe  toxsemia  rarely  to  be  reached  by  any  treatment. 

Treatment:  Rest  in  bed  is  essential  because  of  the  almost 
invariable  cardiac  decompensation.  It  must  be  borne  in 
mind,  however,  that  this  therapeutic  measure  will  now  and 
then  do  more  harm  than  good,  just  as  the  rest,  otherwise  so 
advisable  for  fracture  of  the  neck  of  the  femur,  may  prove 
disastrous  in  patients  past  sixty.     It  is  possible  fatally  to 


DISEASES   OF  THE   URINARY   TRACT.  I47 

upset  the  body's  balance  in  nephritis  as  well  as  in  fractures 
of  elderly  people.  Fortunately  this  well-meant  aggravation 
of  the  disease  through  rest  prescribed  as  a  therapeutic  meas- 
ure, is  a  comparatively  rare  occurrence. 

To  reduce  blood  pressure  by  catharsis,  sweating,  and  occa- 
sionally by  bleeding  is  the  first  and  most  important  task  in 
all  cases  associated  with  hypertension.  If  oedema  is  present 
a  saturated  solution  of  magnesium  sulphate  in  doses  of  from 
one-half  to  one  ounce  of  the  salt  is  the  best  method  of  cathar- 
sis, but  in  the  absence  of  oedema  it  is  better  to  use  elaterium, 
since  magnesium  may  be  absorbed  and  cause  poisoning. 
Daily  catharsis  before  breakfast  is  usually  to  be  advised. 

Sweating  by  means  of  a  hot-air  bath  is  even  more  effective 
than  purgation  and  should  be  carried  out  every  second  day  pro- 
vided the  patient  responds  to  the  heat  and  sweats  profusely. 

Diuretics  are  of  value  only  when  the  cardiac  element  in  the 
case  predominates.  Indeed  their  effectiveness  in  any  given 
case  is  one  of  the  evidences  of  such  predominance.  In  pure 
nephritis  they  have  no  value.  Diuretin  should  be  given  in 
doses  of  15  grains  every  four  hours  in  capsule.  If  no  effect 
is  obtained  within  three  days  the  dose  should  be  doubled  and 
continued  for  three  days  more.  If  it  shows  no  power  to 
increase  the  amount  of  urine  within  six  days  it  should  be 
given  up.  Calomel,  in  doses  of  2  grains  every  four  hours, 
sometimes  succeeds  after  diuretin  has  failed  or  has  lost  its 
efficiency,  but  if  the  kidney  is  seriously  affected  we  must  be 
vigilantly  on  the  watch  against  stomatitis,  and  must  nip  in 
the  bud  any  beginnings  of  this  distressing  symptom. 

Meat  should  be  excluded  from  the  diet  or  given  sparingly 
once  a  day.  Red  meat  is  no  worse  than  white.  Not  more 
than  one  egg  a  day  should  be  allowed  in  most  cases.  On  the 
other  hand,  all  cereals,  vegetables,  and  breadstuffs,  most 
fruits  and  fatty  foods  are  harmless.  The  amount  of  water 
should  be  limited  to  three  pints  unless  an  unbearable  thirst 
is  thereby  produced.  When  oedema  Is  marked,  some  benefit 
may  be  obtained  now  and  then  by  restricting  or  abolishing 
the  amount  of  common  salt  In  the  diet,  but  this  measure 
has  nothing  like  the  width  and  brilliancy  of  application  that 
French  writers  have  led  us  to  anticipate. 


148  CASE   HISTORIES   IN   MEDICINE. 

Cardiac  stimulation  is  of  value  in  the  group  of  cases  bene- 
fited by  diuretin.  Some  preparation  of  digitalis  should  be 
administered  after  the  preliminary  period  of  sweating  and 
purgation  is  over  —  i.e.,  about  the  end  of  the  first  week.  Of 
the  preparations  now  on  the  market  I  prefer  that  known  as 
"  digipuratum,"  1,2  or  3  tablets  a  day  according  to  the  effect 
produced.  Occasionally  one  gets  better  results  for  a  time  by 
combining  or  replacing  this  with  strychnin,  -^-^  or  -^  of  a 
grain  given  subcutaneously  every  four  to  six  hours. 

Doubtless  there  are  many  patients  of  this  type  who  would 
live  longer  in  a  dry,  equable  climate  such  as  that  of  Egypt, 
but  in  my  experience  most  patients  would  rather  die  at  home 
than  live  in  Egypt. 


DISEASES   OF   THE   URINARY   TRACT.  1 49 

Case  53.  A  lawyer  of  forty-seven,  of  good  family  history, 
and  previous  health,  had  complained  for  many  years  of  dys- 
pepsia. He  had  been  noticed  to  be  losing  flesh  for  three  or 
four  months  and  to  have  grown  pale.  Frequent  headaches, 
weakness,  and  shortness  of  breath  on  exertion  have  troubled 
him.  An  oculist  whom  he  consulted  referred  him  to  his 
family  physician,  who  found  pallor,  diminished  eyesight,  full- 
ness of  eyelids,  increased  pulsation  in  the  neck,  dyspnoea,  and 
exaggerated  heart  action. 

The  apex  was  in  the  sixth  interspace,  mammary  line.  The 
heart  sounds  were  loud,  and  the  valvular  sounds  at  the  base 
were  accentuated ;  respiratory  sounds  at  the  base  of  the  right 
chest  behind  were  lessened,  and  numerous  fine  moist  r^les 
could  be  heard  in  lower  portions  and  in  the  anterior  margin 
of  each  lung.  Abdomen  negative.  There  was  swelling  of 
feet  and  ankles,  and  the  patient  stated  that  at  times  his  hands 
seemed  larger  than  usual.  Urine  loii;  pale.  Albumin,  a 
trace.  Granular  and  hyalin  casts,  and  fatty  elements  were 
found  in  considerable  number.  The  patient  also  mentioned 
cough,  with  thin,  frothy  expectoration,  and  that  of  late  mic- 
turition at  night  had  annoyed  him,  and  that  the  quantity  of 
urine  voided  in  twenty-four  hours  was  increased. 

Within  three  months  there  was  gradual  change  for  the 
worse,  and  after  a  day  of  considerable  exposure  he  had  a 
chill,  severe  headache,  and  oliguria.  He  was  found  in  bed 
unconscious,  on  the  tjiird  day  after  the  chill,  and  died  on  the 
following  afternoon. 

1.  What  was  the  condition  in  the  lungs?     (Edema  of  both; 

right  hydro  thorax. 

2.  Causes  of  diminished  respiration  below  the  right  scapula? 

Effusion  (inflammatory  or  dropsical),  thickened  pleura, 
solidification  (pneumonic,  tuberculous,  cancerous),  atel- 
ectasis, enlargement  or  upward  displacement  of  the  liver. 

3.  Causes  of  painless  swelling  of  both  hands  ?     Nephritis,  hot 

weather,  trichiniasis,  obstruction  to  the  superior  cava. 

4.  Significance  of  frequent  nocturnal  micturition?     Prostatic 

obstruction,  chronic  nephritis,  nervousness  (in  women). 

5.  (a)  Causes  for  accentuation  of  the  aortic  second  sound? 

Arteriosclerosis,  aneurism,  high  tension  in  the  peripheral 
arteries  (nephritis;  excitement),     (b)   Of  the  pulmonic 


150  CASE   HISTORIES   IN   MEDICINE. 

second  ?  Obstruction  in  the  lungs  due  to  mitral  disease, 
pneumonia,  any  chronic  lung  trouble,  pleurisy,  and 
thoracic  deformities. 

Diagnosis:  Autopsy  showed  chronic  interstitial  nephritis, 
cardiac  hypertrophy  and  dilatation,  general  oedema.  Death 
from  uraemia.  Retinal  haemorrhages  had  been  found  by  the 
oculist. 

Prognosis:  After  retinal  haemorrhages  are  found  patients 
seldom  live  a  year.  Otherwise  the  duration  of  life  is  difficult 
to  predict.  It  depends  on  the  patient's  ability  and  willingness 
to  undergo  proper  treatment,  the  response  of  his  organs  to 
such  treatment,  and  the  occurrence  of  complications. 

Treatment :  Good  hygiene  with  the  avoidance  of  strain  and 
worry;  dry,  warm  climate,  such  as  Egypt;  sweating  and  purga- 
tion each  once  or  twice  a  week;  restriction  of  liquids  and  re- 
placement of  table  salt  by  sodium  bromide  (see  also  Case  52). 


DISEASES   OF   THE   URINARY   TRACT.  I5I 

Case  54.  A  child,  seven  years  of  age,  of  healthy  parentage, 
had  made  frequent  complaint  of  pain  in  the  left  side  of  abdo- 
men and  was  found  by  her  mother  to  be  rapidly  losing  flesh 
and  strength.  There  was  also  an  account  of  quite  frequent 
voiding  of  high-colored  urine,  with  a  brownish  sediment. 

After  several  weeks,  the  emaciation  progressing,  the  mother 
noticed  that  the  left  side  of  the  abdomen  was  larger  than  the 
right;  that  there  was  pain  and  tenderness  on  pressure,  and 
that  periods  of  "  constipation  "  occurred,  followed  by  the 
escape  of  large  quantities  of  semi-liquid  feces,  without  much 
change  in  the  size  of  abdomen  or  relief  to  the  pain  and  tender- 
ness in  left  lumbar  region. 

About  this  time  the  patient  was  taken  to  a  physician,  who 
confirmed  the  mother's  observation  of  loss  of  flesh  and 
strength,  for  the  child  was  pale  or  sallow,  emaciated,  and 
extremely  weak.  In  the  left  lumbar  region  a  mass,  irregular 
in  outline  and  surface,  painful  on  palpation,  extended  into  the 
umbilical  region  and  upwards  to  the  margin  of  ribs  in  front; 
percussion  showed  tympanitic  resonance  over  the  central 
portion  of  the  tumor.  Elsewhere  the  tumor  was  fiat  on 
percussion. 

A  specimen  of  urine  showed  an  acid  reaction,  specific  gravity 
1014;  sediment,  brownish  and  consisting  of  blood  and  brown 
granular  matter.  There  were  no  casts,  and  the  quantity  of 
albumin  present  was  small. 

1.  What  abdominal  tumors  are  most  frequent  in  children? 

Hypernephroma,  congenital  cystic  kidney,  dilated  colon, 
secondary  enlargements  of  spleen  and  liver. 

2.  How  are  tumors  of  the  kidney  to  be  distinguished  from 

enlargement  of  the  spleen?  The  sharp  edge  of  the 
spleen  and  Its  notch  can  usually  be  felt.  The  kidney 
produces  a  rounded  tumor  palpable  bimanually  with 
one  hand  In  the  flank.  The  inflated  colon  traverses 
tumors  of  the  kidney  but  passes  behind  those  of  the 
spleen. 

Diagnosis:  The  age,  the  tumor,  the  emaciation,  the  haema- 
turia  without  casts,  the  apparent  anaemia,  strongly  suggest 
malignant  disease  of  the  kidney,  and  at  this  age  hypernephroma 
is  the  commonest  type  of  malignant  disease.  Congenital  cystic 
disease  of  the  kidneys  does  not  produce  such  cachexia  and  Is 


152  CASE   HISTORIES   IN   MEDICINE. 

almost  never  associated  with  haematuria.  The  condition  of 
the  bowels  excluded  dilated  colon.  The  characteristics  of  this 
tumor  are  not  those  of  a  spleen.  The  tympanitic  resonance 
over  its  center  is  very  possibly  due  to  the  colon. 

Prognosis:  I  will  take  for  granted  that  this  was  a  case  of 
hypernephroma.  It  occurred  before  the  present  classifica- 
tion of  renal  and  adrenal  tumors  had  been  worked  out,  but 
probably  belongs  to  the  adrenal  group.  At  the  time  when 
the  diagnosis  of  such  a  tumor  is  made  the  outlook  is  usually 
hopeless,  for  it  is  very  often  the  metastases  in  bone  which 
give  us  our  first  unmistakable  evidence  of  the  existence  of  an 
adrenal  growth.  There  is  reason  to  believe  that  these  tumors 
remain  latent  and  symptomless  for  years.  Some  of  them 
show  their  presence  only  by  an  occasional  attack  of  haema- 
turia. If  they  can  be  recognized  at  this  period,  the  outlook 
may  be  favorable  with  radical  operation.  There  is  no  hope 
for  more  than  a  year  of  life  for  those  in  whom  metastases  have 
been  discovered.  With  the  radical  removal  of  a  tumor  which 
has  not  produced  metastases  we  may  hope  for  permanent 
recovery. 

Treatment:  Early  and  radical  surgery  is  the  only  thing 
which  a  physician  can  recommend  in  cases  free  from  metas- 
tases. In  those  that  are  too  ill  for  operation,  or  that  refuse  it, 
one  can  merely  meet  the  symptoms  as  they  arise.  Possibly 
something  may  be  accomplished  also  by  X-ray  treatment. 


DISEASES   OF   THE    URINARY   TRACT.  1 53 

Case  55.  An  Italian  laborer  of  fifty-six  entered  the  hospital 
August  28,  1910.  His  family  history  was  negative.  He  had 
been  in  the  United  States  twenty-two  years.  Thirty  years 
ago  he  had  had  a  severe  haemorrhage  "  from  the  mouth  "  and 
was  sick  a  week.  Three  years  ago,  chills  and  fever;  two 
years  ago  a  severe  cough  began  and  has  persisted  ever  since. 
One  year  ago  he  had  slight  haemoptysis  for  a  week;  this  had 
occurred  three  or  four  times  since.  He  has  never  been  sick 
in  bed,  and  denies  venereal  disease.  He  has  smoked  a  good 
deal,  and  drank  heavily  until  two  years  ago,  since  which  time 
moderately. 

The  patient  now  complains  of  oliguria,  abdominal  pain, 
nausea,  and  vomiting.  Fifteen  days  ago  he  went  to  bed  with 
severe  cough,  raising  considerable  sputum  which  showed  no 
blood.  This  cough  subsided  three  days  ago.  Since  then  he 
has  felt  worse  because  of  increase  of  symptoms  above  noted. 

Urine  is  passed  two  or  three  times  during  the  day,  once  or 
twice  at  night.  The  urine  appears  normal.  For  the  last 
three  or  four  days  he  has  had  three  or  four  bloody  movements 
from  the  bowels  daily.  His  appetite  has  been  good,  but 
eating  causes  "  pain  in  the  stomach."  Last  night  he  vomited 
three  or  four  times,  and  was  unable  to  keep  anything  on  his 
stomach.  He  slept  poorly  for  some  weeks  because  of  abdom- 
inal pain.     He  has  had  no  known  loss  of  weight. 

Examination:  The  patient  was  well-developed  and  nour- 
ished, somewhat  ''  dopy,"  the  mucous  membranes  slightly 
pale.  He  had  no  jaundice;  the  pupils  and  reflexes  were  nor- 
mal; the  tongue  showed  a  brown  coat;  no  lead-line  on  teeth. 
The  left  border  of  cardiac  dulness  was  normal ;  the  right  border 
2.5  cm.  from  mid-sternum.  The  sounds  were  regular,  distant, 
of  fair  quality,  no  murmurs.  The  pulmonary  second  was 
greater  than  the  aortic  second,  not  accentuated. 

Throughout  both  lungs  there  was  increased  resonance, 
diminished  breathing,  prolonged  expiration.  Many  fine  rales 
were  heard  at  the  right  base.  The  abdomen  was  level, 
tympanitic,  no  palpable  masses;  there  was  involuntary  right- 
sided  spasm,  and  considerable  tenderness  in  right  upper 
quadrant.  The  liver  dulness  extended  from  the  fifth  space 
to  the  costal  margin.     The  edge  of  the  spleen  was  not  felt 


154  CASE   HISTORIES   IN   MEDICINE. 

and  there  was  no  oedema.  The  rectal  examination  was 
negative. 

The  temperature  was  99°,  pulse  82,  respiration  25.  The 
urine  was  turbid,  acid,  specific  gravity  1012,  albumin  slight 
trace,  sugar  o;  sediment  negative.  Blood:  Hgb.  75%,  whites 
22,500;  the  smear  showed  polynuclear  leucocytosis.  The  spu- 
tum was  thin,  yellowish  green,  purulent,  showing  no  particular 
organisms ;  no  tuberculosis.  The  stools  gave  a  positive  guaiac 
test  and  showed  considerable  pus. 

The  patient  remained  in  the  hospital  four  days,  during 
which  time  he  could  take  nothing  by  mouth,  was  unable  to 
retain  enemata,  and  passed  pure  pus  by  rectum.  The  spasm 
and  tenderness  in  the  right  upper  quadrant  persisted.  Urine 
was  obtained  only  by  catheterization.  He  raised  very  little 
sputum  although  his  lungs  were  full  of  rales;  the  bacterial 
contents  of  the  sputum  and  the  pus  from  rectum  were  similar. 
The  patient's  condition  prevented  any  operative  interference; 
his  respirations  rose,  became  shallow  and  labored,  and  he  died 
quietly. 

Diagnosis:  The  presence  of  vomiting  and  the  stuporous 
condition  not  otherwise  accounted  for,  suggests  at  once  the 
possibility  of  kidney  disease.  The  nocturnal  urination  might 
support  this  diagnosis  provided  we  are  sure  that  there  is  no 
marked  enlargement  of  the  prostate. 

The  presence  of  pus  in  the  bowel  movements  together  with 
a  positive  guaiac  test  makes  it  practically  certain  that  we  are 
dealing  with  an  ulcerative  colitis.  In  persons  of  this  patient's 
age  a  colitis  complicating  chronic  nephritis  is  not  at  all  un- 
common. The  tenderness  in  the  upper  right  quadrant  may 
however  possibly  be  explained  as  the  result  of  the  colitis. 

The  condition  of  the  lungs  suggests  tuberculosis  and  the 
negative  sputum  examination  is  insufficient  to  exclude  this 
diagnosis  although  the  physical  signs  are  by  no  means  char- 
acteristic, especially  in  the  absence  of  fever. 

Considerable  light  was  thrown  upon  the  diagnosis  by  the 
demonstration  of  a  positive  Wasserman  test  in  the  blood. 
In  view  of  the  results  of  this  test  one  must  consider  the 
possibility  of  an  amyloid  nephritis,  but  with  the  evidence  be- 
fore us  one  cannot  speak  more  definitely.     The  question  of 


DISEASES   OF   THE   URINARY    TRACT.  1 55 

perforation  of  a  dysenteric  ulcer  was  considered  in  view  of 
the  marked  localized  abdominal  tenderness,  and  but  for  the 
patient's  poor  general  condition  an  exploratory  excision  would 
doubtless  have  been  undertaken  to  settle  this  point. 

Prognosis:  Assuming  that  the  diagnosis  is  a  chronic  ne- 
phritis, possibly  amyloid,  with  a  secondary  colitis  and  severe 
bronchitis,  the  outlook  would  of  course  be  grave.  The  patient 
whose  nephritis  is  so  far  advanced  that  complications  of  this 
type  are  present  rarely  lives  more  than  a  few  months;  yet 
we  were  not  prepared  for  so  rapidly  fatal  an  issue  as  actually 
occurred. 

Treatment:  Had  the  patient  been  able  to  take  food  by 
mouth  we  should  have  allowed  him  a  liberal  diet,  excluding 
only  such  things  as  were  positively  indigestible;  though  his 
kidneys  were  presumably  damaged,  his  general  nutrition  is 
of  greater  importance  than  any  attempt  to  spare  his  kidneys. 
In  the  absence  of  oedema  there  would  appear  to  be  no  reason 
for  purging  or  sweating  the  patient,  since  we  have  no  reason 
to  believe  that  we  can  get  out  of  the  body  any  substance  except 
water  by  this  means.  The  idea  that  poisonous  salts  can  be 
removed  by  sweating  or  purging  seems  to  have  no  sufficient 
foundation.  If  the  condition  of  the  kidney  was  to  improve, 
or  if  it  seemed  at  the  outset  to  permit,  antisyphilitic  treatment 
would  be  in  order,  although  it  would  of  course  have  no  influ- 
ence upon  an  organ  which  had  reached  the  stage  of  amyloid 
degeneration. 

For  the  colitis  our  best  efforts  should  be  directed  towards 
improving  the  general  nutrition  of  the  intestinal  wall,  first  by 
a  highly  nutritious  diet,  and  complete  rest  in  bed,  secondly, 
by  irrigation  of  the  intestin  with  water  of  the  body  tempera- 
ture. I  have  never  been  convinced  that  the  addition  of  any 
medicament  to  the  water  that  is  used,  renders  it  any  more 
effective.  Cleanliness  is  our  main  object.  For  the  pulmo- 
nary complication  no  treatment  at  present  seems  necessary. 


156  CASE   HISTORIES   IN   MEDICINE. 

Case  56.  Fireman,  fifty-seven  years  old,  had  scarlet  fever 
at  nine  years,  apparently  without  ill  results.  Otherwise  he 
has  been  always  well  till  six  months  ago,  when  on  a  vacation 
he  ate  some  canned  oysters  in  the  form  of  a  stew.  One-half 
hour  afterwards  his  breath  was  suddenly  shut  off.  No  pain, 
vomiting,  or  other  symptoms.  Troubled  with  respiration  ever 
since  when  in  midst  of  fire  smoke.  Lost  30  pounds  in  three 
months.  Four  weeks  ago,  when  turning  in  bed,  noticed  a 
swelling  in  the  left  loin  which  seemed  to  move  with  change  of 
position.     No  pain  or  tenderness  and  no  change  in  urine. 

Examination:  On  left  side  two  tumors  are  felt  below  the 
ribs;  one  (above  and  in  front)  feels  like  a  spleen.  The  other 
is  more  rounded  and  deeper.  Both  move  with  respiration. 
The  lower  tumor  is  somewhat  tender  and  apparently  elastic. 
Belly  otherwise  negative.  Lungs  negative.  Heart  not  re- 
markable except  for  a  loud  ringing  aortic  second  sound. 
Brachials  tortuous  and  move  laterally.  Urine  1018,  40  ounces 
in  twenty-four  hours.  Slight  trace  of  albumin.  Few  hyaHn 
and  fine  granular  casts,  some  with  cells  or  fat  on  them.  Blood 
normal,  no  fever. 

1.  What  are  the  common  causes  for  the  appearance  of  slight 

dyspnoea  in  a  man  of  fifty-seven?  Arteriosclerosis  and 
its  results,  emphysema,  obesity. 

2.  What  was  the  action  of  the  canned  oysters?     Possibly 

dyspeptic  flatulence,  embarrassed  cardiac  action  by 
direct  pressure  through  the  diaphragm.  Probably, 
however,   the  association  was  accidental. 

3.  (a)  What  abdominal  tumors  move  most  freely  with  res- 

piration? Those  connected  with  the  liver,  stomach,  and 
spleen,  (b)  What  least  freely  ?  Those  connected  with 
the  kidney  and  pancreas. 

4.  Enumerate  some  of  the  conditions  in  which  such  a  urine 

is  often  seen.  In  passive  congestion,  fevers,  and  after 
exertion,  when  there  is  bile  or  sugar  in  the  urine,  in 
arteriosclerosis  and  chronic  interstitial  nephritis. 

5.  What  important  and  simple  methods  of  examination  have 

been  omitted?  Inflation  of  the  colon,  palpation  in  a 
warm  bath. 

6.  What  questions  should  be  asked  with  reference  to  the  loss 

of  weight?  Have  appetite  and  sleep  been  as  good  as 
usual  ? 


DISEASES   OF  THE   URINARY  TRACT.  1 57 

Diagnosis:  An  abdominal  tumor,  painless,  slow  growing, 
and  producing  little  or  no  disturbance  of  any  function,  is  the 
chief  feature  of  the  case.  The  tumor  occupies  more  nearly 
the  position  of  the  left  kidney  than  of  any  other  organ.  It  is 
rounded  and  elastic.  Renal  abscess,  cyst,  neoplasm,  or  hydro- 
nephrosis suggest  themselves.  The  absence  of  fever,  pyuria, 
leucocytosis,  and  pain  are  against  abscess,  and  the  absence  of 
any  pain  or  disturbance  of  micturition  make  hydronephrosis 
unlikely.  Hypernephroma  usually  occurs  in  younger  people 
and  often  produces  haematuria  and  bone  metastases.  It  can- 
not however  be  excluded  here.  The  inflated  colon  traverses  the 
tumor.  At  operation  a  congenital  cystic  kidney  weighing  870 
grams  was  found  and  removed.  The  dyspnoea,  however,  con- 
tinued, and  a  year  later  autopsy  showed  general  arterioscle- 
rosis with  cardiac  hypertrophy  and  dilatation,  general  passive 
congestion,  and  terminal  streptococcus  sepsis.  The  remaining 
kidney  was  also  cystic. 

Prognosis  and  Treatment  are  sufficiently  suggested  in  what 
has  been  said  (see  also  Case  53). 


158  CASE   HISTORIES    IN   MEDICINE. 

Case  57.  A  woman,  fifty-four  years  old,  was  seen  May  19. 
Only  an  imperfect  history  was  obtained  as  she  spoke  but  little 
English.  She  had  been  pale  for  several  years,  and  for  over 
two  years  she  has  passed  bloody  urine  from  time  to  time. 
She  has  been  gradually  losing  strength  and  flesh,  and  growing 
more  and  more  short  of  breath  on  exertion.  Two  months 
ago  she  went  to  bed  on  account  of  weakness.  Lately  she  has 
vomited  occasionally,  the  vomitus  containing  nothing  unusual. 

Examination  showed  a  very  poorly-nourished  woman  with 
a  marked  loss  of  subcutaneous  fat.  The  conjunctivae  were 
bluish.  The  mucous  membranes  were  pale,  and  the  skin 
was  an  extremely  pale  lemon  yellow  color.  The  right  border 
of  cardiac  dulness  was  a  finger's  breadth  and  a  half  to  the 
right  of  the  parasternal  line;  the  left  extended  to  the  nipple 
line.  A  well-marked  systolic  murmur  was  heard  over  the 
whole  precordium  and  was  transmitted  upward  into  the  ves- 
sels of  the  neck  and  outward  into  the  axilla.  The  points 
of  maximum  Intensity  were  In  the  third  left  Interspace  and  at 
the  apex.  The  second  pulmonic  sound  was  accentuated. 
There  were  a  few  rales  at  the  bases  of  both  lungs.  The  liver 
and  spleen  were  normal.  Beneath  the  right  costal  margin 
on  full  Inspiration  the  lower  portion  of  a  somewhat  irregular 
body,  which  seemed  about  four  Inches  wide  and  three  inches 
in  thickness,  could  be  felt  on  bimanual  palpation.  It  disap- 
peared during  expiration.  There  was  oedema  of  the  feet  and 
ankles.  The  temperature  has  been  Irregular,  ranging  from 
normal  to  100°.  Pulse  weak,  regular,  120.  Respiration  26. 
One  examination  of  the  urine  showed  It  to  be  turbid,  acid, 
and  with  a  specific  gravity  of  1013.  Albumin  a  large  trace. 
The  sediment  contained  much  pus,  free  and  In  clumps,  con- 
siderable normal  and  abnormal  blood,  and  much  squamous 
epithelium.  A  second  specimen  was  noticeably  red  In  color, 
the  amount  of  albumin  was  larger  and  there  was  distinctly 
more  normal  and  abnormal  blood  in  the  sediment;  otherwise 
the  characteristics  were  the  same.  Examination  of  the  blood 
was  as  follows:  reds  1,280,000;  whites  8000;  Hgb.  10%.  There 
was  marked  polkllocytosis,  macro-  and  microcytosis,  and  some 
polychromatophllia.  The  differential  count  of  the  white  cells 
was  as  follows: 


DISEASES  OF   THE    URINARY   TRACT.  1 59 

Small  mononuclears  12%;  large  mononuclears  37%;  poly- 
nuclears  48%;  eosinophiles  3%.  Two  normoblasts  and  two 
megaloblasts  were  seen  in  counting  100  white  cells. 

Diagnosis:  The  salient  points  of  this  case  seem  to  be  as 
follows:  A  woman  past  middle  life  begins  to  lose  flesh  and 
strength  and  to  pass  bloody  urine.  An  irregular  tumor  is 
felt  in  the  region  of  the  right  kidney.  An  intense  anaemia 
complicates  these  symptoms.  The  urine  contains  blood  and 
pus,  but  shows  no  distinct  signs  of  nephritis.  The  anaemia  is 
apparently  of  the  secondary  type  although  there  is  no  leuco- 
cytosis  and  no  distinct  statement  as  to  the  presence  or  ab- 
sence of  achromia.  With  so  low  a  haemoglobin,  however 
(color  index  less  than  .5),  we  may  assume  that  there  was  a 
well-marked  achromia.  This  point  is  of  considerably  more 
importance  than  the  presence  of  megaloblasts  and  the  low 
percentage  of  polynuclear  cells.  With  the  exclusion  of  per- 
nicious anaemia,  then,  from  consideration,  we  have  no  diffi- 
culty in  deciding  that  we  are  dealing  with  a  renal  neoplasm. 
Statistics  show  that  by  far  the  commonest  tumor  in  this 
region  is  the  hypernephroma  and  this  accordingly  should  be 
our  diagnosis. 

Prognosis:  If  operation  is  performed  early,  recovery  may 
in  rare  cases  be  complete.  In  the  majority  of  cases,  how- 
ever, metastases  have  already  been  sown  here  and  there. 

Treatment:  Operation  should  be  performed  as  soon  as  the 
diagnosis  is  made.     There  is  no  other  justifiable  treatment. 


CHAPTER   IV. 
DISEASES    OF   THE    CIRCULATION. 

Case  58.  A  college  student  of  twenty,  a  member  of 
an  outdoor  engineering  class  during^  the  summer  vacation, 
suddenly  fell  while  at  work  in  the  field  five  weeks  before  the 
time  when  I  saw  him.  He  was  taken  home  and  found  to 
have  a  temperature  of  103°  and  a  positive  Widal  reaction. 
After  this  he  ran  a  typical  typhoid  temperature  for  three 
weeks  with  a  normal  defervescence,  but  the  Widal  reaction 
was  twice  found  negative  near  the  end  of  the  febrile  period. 
There  followed  ten  days  of  normal  convalescence.  The 
patient  was  up  and  able  to  walk  about.  An  attempt  was 
made  to  move  him  to  his  home  which  was  fifty  miles  away, 
but  after  driving  a  short  distance  he  suddenly  collapsed  with 
a  rapid,  Irregular  pulse,  a  marked  dyspnoea,  enlarged  heart, 
and  albuminuria. 

It  was  then  recalled  that  he  had  had  headaches  all  his  life, 
especially  when  he  got  nervous,  and  that  three  years  ago  he 
had  had  a  mild  case  of  scarlet  fever. 

The  patient  was  seen  October  10  at  the  hotel  wherein  his 
collapse  had  occurred.  His  chief  complaint  was  then  of  gas 
which  accumulated  in  great  volume  In  his  stomach  every 
afternoon,  and  unless  discharged  produced  palpitation,  vertigo 
and  great  discomfort.  He  felt  otherwise  well  but  could  not 
raise  his  head  without  palpitation  and  vertigo.  He  was  lying 
fiat  in  bed,  breathing  easily.  His  pupils  were  both  very  large, 
his  color  bright  but  changeable,  going  and  coming  on  slight 
provocation.  As  soon  as  I  began  to  listen  to  his  heart  there 
were  loud  rumblings  and  explosive  sounds  as  If  gas  were 
being  expelled  from  the  stomach.  This  ceased  when  the 
chest  examination  was  finished.  No  enlargement  of  the  heart 
could  be  made  out.  A  faint  systolic  murmur  was  audible 
throughout  the  precordia  and  the  pulmonic  second  was  some- 

160 


DISEASES    OF   THE    CIRCULATION.  l6l 

what  louder  than  the  aortic  second  sound.  The  lungs  were 
negative,  likewise  the  abdomen  and  extremities,  although  the 
knee-jerks  were  very  active.  I  suggested  that  he  should  sit 
up.  The  preliminary  process  of  getting  on  a  dressing-gown 
caused  the  patient  much  fatigue,  and  as  soon  as  he  assumed 
the  upright  position  he  began  to  have  a  rapid,  irregular  res- 
piration accompanied  by  sighs  and  moans  with  very  marked 
vertigo  and  fain tness.  The  heart  rate  rose  to  1 30.  No  aryth- 
mla.  He  was  all  right  as  soon  as  he  was  allowed  to  lie  down 
again.  A  specimen  of  urine  was  examined  at  once.  It  was 
clear,  normal  in  color,  1025  in  specific  gravity,  contained  no 
albumin,  no  sugar.     The  blood  was  normal. 

The  diagnosis  of  the  attending  physician  was  chronic  inter- 
stitial nephritis  with  dilated  heart. 

1.  What  suspicions  should  be  aroused  and  what  tests  should 

be  made  owing  to  the  manner  In  which  the  gaseous 
distention  occurred  ?  It  is  in  all  probability  due  to 
"  cribbing."  One  should  watch  carefully,  holding  a 
feather  to  the  lips,  to  see  whether  the  gas  or  other  air 
Is  not  being  sucked  in  previous  to  its  expulsion. 

2.  What  other  signs  suggest  a  neurotic  basis  for  this  patient's 

collapse?  The  large  pupils,  the  facial  blushing,  the 
lively  knee-jerks  and  the  entire  comfort  of  the  patient 
In  a  recumbent  position. 

3.  What  further  tests  should  be  made  to  exclude  the  possi- 

bility of  chronic  nephritis  ?  The  blood  pressure  should 
be  measured.  This  was  done  and  showed  a  systolic 
pressure  of  120  mm.  Hg.  A  nephritis  of  three  years' 
duration,  such  as  was  here -suspected,  would  certainly 
have  produced  a  demonstrable  cardiac  hypertrophy  with 
vascular  hypertension.     Both  were  here  absent. 

Diagnosis:  The  diagnosis  of  cardiac  neurosis  seems  evi- 
dent when  nephritis  and  the  supposedly  resultant  dilatation 
are  excluded.  It  is  possible  that  a  certain  degree  of  post- 
febrile myocarditis  may  be  present,  but  if  the  original  in- 
fection was  really  typhoid  this  seems  unlikely,  since  the 
myocardial  weakness  of  typhoid  is  much  more  manifest  during 
the  fever  than  in  convalescence.  I  have  never  known  signs 
of  marked  myocardial  weakness  following  typhoid. 

There  seemed  no  reason  to  interpret  the  murmur,  audible 
all  over  the  precordia,  as  evidence  of  endocarditis,  especially 


1 62  CASE   HISTORIES    IN   MEDICINE. 

in  the  absence  of  fever  and  leucocytosis.  Such  murmurs  are 
very  common  after  any  pyrexia. 

Prognosis:  The  boy  should  be  able  to  get  up  and  about 
within  a  few  days,  though  he  will  doubtless  need  considerable 
urging  as  he  is  thoroughly  frightened  about  himself.  The 
doctor's  grave  diagnosis  had  evidently  become  suspected  by 
the  patient,  perhaps  because  of  the  constant  presence  of 
his  father  and  mother,  who  had  come  at  once  from  their  dis- 
tant home  and  were  naturally  much  concerned  about  their 
only  son. 

Treatment:  The  patient  should  be  made  to  sit  up  for  in- 
creasing periods  daily.  The  nature  and  mechanism  of  his 
''  cribbing  "  should  be  explained  to  him.  Within  a  few  days 
he  should  be  urged  to  walk,  and  as  soon  as  this  is  easy  for 
him  he  should  be  moved  to  his  home. 

This  treatment  was  carried  out.  In  ten  days  he  was  able 
to  walk  about  freely,  and  nineteen  days  after  the  time  when 
I  saw  him  he  made  the  trip  to  his  home  by  train  without  any 
trouble.     Convalescence  was  then  uninterrupted. 


DISEASES    OF    THE    CIRCULATION.  1 63 

Case  59.  Mrs.  J.,  sixty-five,  an  active,  spare,  energetic 
woman.  Always  well.  For  two  years  has  noticed  some 
dyspnoea  on  exertion.  Two  weeks  ago  had  an  attack  of 
dyspepsia  with  dizziness.  This  evening  she  ate  a  hearty 
supper  of  chopped  codfish  and  potatoes  warmed  up  in  pork 
fat.  Immediately  afterwards  she  started  out  for  a  walk. 
After  walking  about  a  quarter  of  a  mile  she  noticed  dyspnoea, 
which  rapidly  increased  to  great  distress.  On  reaching  a 
friend's  house  she  had  barely  strength  to  enter. 

When  seen  t\venty-five  minutes  later,  the  patient  was 
sitting  up  propped  by  pillows.  Respiration  was  from  30  to 
40  per  minute,  and  was  accompanied  by  a  loud  rattle  in  the 
throat.  The  larynx  moved  violently  up  and  down.  No  pain 
anywhere.  The  face  was  drawn  and  blue,  nose  pinched, 
hands  and  fingers  purple,  skin  cold  and  clammy.  The 
carotids  were  throbbing  strongly,  the  heart  beating  tem- 
pestuously— 140  times  per  minute.  The  lungs  were  full  of 
coarse,  medium,  and  fine  rales  up  to  the  second  rib  on  each 
side.  Owing  to  the  noisy  breathing  no  definite  information 
could  be  obtained  regarding  the  cardiac  valves. 

1.  Significance  of  the  rattle  in  the  throat?     Tracheal  rales 

occur  whenever  inflammatory  or  dropsical  fluid  accu- 
mulates in  the  trachea,  owing  to  coma  or  to  weakness 
which  renders  the  patient  unable  to  raise  and  expecto- 
rate or  swallow  the  fluid.  It  is  a  bad  sign,  because  it 
means  either  very  deep  (and  therefore  serious)  coma, 
or  very  severe  prostration. 

2.  Significance  (a)  of  throbbing  carotids?  (b)  of  other  cervi- 

cal pulsations?  (a)  Throbbing  carotids  mean  violent 
heart  action,  low  arterial  tension,  or  both.  They  are 
seen  in  cardiac  hypertrophy  from  any  cause,  especially 
in  aortic  regurgitation,  in  nervous  persons,  and  in  marked 
anaemia,  {b)  Aneurism,  a  normal  subclavian  artery 
crossing  a  cervical  rib,  the  normal  (diastolic)  undula- 
tion of  cer\acal  veins,  and  the  systolic  venous  pulse  of 
tricuspid  leakage  should  be  remembered. 

3.  What   further   data  should   be   obtained   at   once  ?     The 

strength  and  rhythm  of  the  pulse  (far  more  important 
than  its  rate),  the  temperature,  the  urine. 

4.  How  is  the  prognosis  influenced  by  the  mode  of  onset 

here  ?     Such  symptoms  arising  without  assignable  cause 


164  CASE   HISTORIES   IN   MEDICINE. 

are  more  serious  than  their  appearance  after  (probable) 
indigestion  and  exertion  as  here. 
5.    Evidence  against  pneumonia  here?     The  onset   without 
chill  or  pain;  the  cardiac  origin  of  symptoms;  the  ab- 
sence of  fever,  and  of  signs  of  solidified  lung. 

Diagnosis:  The  lung  signs  are  those  of  acute  pulmonary 
oedema  due  to  weak  heart  action,  such  as  is  often  brought  on 
by  slight  indigestion  and  exertion  in  an  elderly  person  whose 
myocardium  is  weak.  Bronchial  asthma  might  produce 
similar  pulmonary  signs,  but  practically  never  occurs  at  the 
age  of  sixty-five  in  a  person  previously  well.  Renal  asthma 
rarely  has  so  sudden  an  onset  without  previous  evidences  of 
uraemia,  dropsy,  or  cardiac  weakness. 

Prognosis:  The  acute  pulmonary  oedema  which  compli- 
cated the  underlying  arteriosclerotic  degeneration,  will  be 
discussed  first.  The  initial  attack  is  rarely  fatal.  As  a 
rule  the  patient  has  three  or  four  such  seizures  and  some- 
times they  may  pass  off  altogether,  so  that  the  patient  dies  of 
some  other  result  of  the  underlying  arteriosclerosis  or  of  some 
intercurrent  infection.  It  depends  upon  the  patient's  abil- 
ity and  willingness  to  limit  his  expenditures  of  mental  and 
physical  energy.  The  average  attack  of  pulmonary  oedema 
lasts  less  than  twenty-four  hours  in  its  severest  form,  and 
leaves  the  patient  weakened  for  five  to  ten  days  thereafter. 
There  is,  of  course,  a  marked  tendency  to  relapse.  For  the 
prognosis  of  the  underlying  arteriosclerosis  see  Case  60. 

Treatment:  I  am  not  satisfied  that  any  of  the  drugs 
enthusiastically  recommended  by  one  or  another  observer 
has  any  definite  effect.  In  the  recent  discussion  among 
the  members  of  the  Association  of  American  Physicians, 
drugs  such  as  adrenalin  and  nitroglycerin  were  equally 
praised  although  their  effects  are  of  course  precisely  opposite. 
From  the  animal  analogies  it  would  appear  that  the  use  of 
artificial  respiration  should  be  more  effective  than  any  other 
measure  and  In  a  few  cases  this  has  apparently  proved  of 
great  value  in  the  human  being.  It  must  be  borne  in  mind, 
however,  that  the  average  case  of  genuine  acute  pulmonary 
oedema  tends  strongly  to  swift  and  spontaneous  recovery. 


DISEASES   OF   THE    CIRCULATION.  1 65 

Case  60.  A  business  man,  fifty-eight,  with  good  family 
history  and  habits,  had,  about  twenty-five  years  ago,  a  severe 
rheumatic  fever,  disabling  him  for  several  months.  Ever 
since  then  his  pulse  has  been  more  or  less  irregular;  but  he 
has  suffered  no  inconvenience  until  about  two  years  ago 
when  he  noticed  that  walking  uphill  caused  dyspnoea.  Since 
then  he  has  lost  upwards  of  fifty  pounds  in  weight.  For  the 
past  three  months  he  has  driven  to  his  business  for  an  hour 
a  day  only,  and  been  kept  awake  by  dyspnoea  and  pain  in 
the  right  side  of  the  abdomen.  Appetite  has  been  poor  and 
digestion  impaired. 

Pulse  irregular,  intermittent,  rapid,  not  corresponding  with 
the  heart-beat.  Respiration  easy  when  quiet,  temperature 
98.6°. 

Complexion  sallow,  with  yellowish  tinge  to  sclerotics.  No 
cyanosis.  Tongue  heavily  coated.  Moderate  oedema  of 
lower  legs.  Lungs  clear.  Cardiac  apex  not  defined  to  eye 
or  touch.  Percussion  shows  increase  in  the  transverse  diam- 
eter of  the  heart,  the  action  of  which  is  so  rapid  and  irregular 
that  only  a  doubtful  systolic  apex  murmur  can  be  heard.  The 
second  sounds  are  clear,  the  pulmonic  not  specially  accented. 

The  belly  is  flabby,  the  navel  not  flushed.  Percussion 
dulness  in  the  flanks  shifts  with  changing  position.  No 
fluctuation  wave.  Three  inches  below  the  right  costal  border 
and  across  the  epigastrium  a  solid  body,  tender,  with  a  firm 
edge  descending  with  inspiration,  is  felt. 

The  urine:  normal  in  amount,  specific  gravity  1028,  contains 
a  large  trace  of  albumin,  2%  of  sugar,  1.26%  urea,  no  bile, 
acetone,  or  diacetic  acid.  Sediment:  a  few  normal  blood 
globules  and  a  rare  hyalin  cast. 

1.  Common  causes  of  sugar  in  the  urine?     Diabetes  mellitus, 

neuroses  (worry,  fear,  etc.),  coma  from  any  cause  (in- 
cluding narcotics),  pregnancy. 

2.  How  do  you  explain  the  loss  of  weight?     Poor  appetite 

and  digestion  combined  with  arteriosclerosis  and  with 
glycosuria. 

3.  Commonest  causes  of  pain  in  that  region  ?     Appendicitis, 

gall-stones,  pelvic  inflammation  (in  women). 

4.  What  caused  the  pain  in  the  right  side  of  the  abdomen  ? 

Hepatic  congestion. 


1 66  CASE   HISTORIES   IN   MEDICINE. 

Diagnosis:  Dyspnoea,  digestive  disturbance,  a  dilated, 
rapid,  and  irregular  heart,  swollen  legs,  ascites,  enlarged  liver 
with  slight  jaundice  and  a  urine  showing  renal  congestion, 
all  point  to  an  uncompensated  cardiac  lesion  with  passive 
congestion  of  the  lungs,  stomach,  liver,  peritoneal  cavity, 
kidney  and  legs.  The  exact  condition  of  the  heart  cannot  be , 
stated.  Its  insufhcient  strength  may  be  due  to  mitral  regur- 
gitation produced  by  the  old  rheumatic  endocarditis  (see  his- 
tory) and  compensated  until  two  years  ago.  It  is  more  likely 
to  be  a  myocardial  weakness  (with  or  without  mitral  disease) 
that  produces  the  poor  heart  action.  He  is  at  the  age  for 
arteriosclerosis  and  so  for  myocardial  weakness,  but  we  have 
no  data  here  as  to  his  arteries.  The  glycosuria  will  probably 
persist.     If  so  it  is  to  be  classed  as  diabetes. 

Prognosis:  In  the  whole  field  of  medicine  I  know  no  more, 
difficult  and  uncertain  prognosis  than  that  relating  to  the 
myocardial  weakness  associated  with  arteriosclerosis.  Many 
a  patient  whom  some  competent  observer  has  doomed  to 
death  within  a  few  weeks  survives  for  years  to  laugh  at  the 
prophecy.  On  the  other  hand,  I  remember  a  case  in  which 
the  consultant  had  given  an  excellent  prognosis,  yet  received 
on  his  way  home  a  telephone  message  stating  that  the  patient 
had  died  within  half  an  hour  of  the  doctor's  visit.  Despite 
these  difficulties  we  may  say  in  the  first  place  that  most  cases 
live  for  a  number  of  years  after  their  symptoms  begin  to 
be  troublesome.  Factors  which  influence  the  prognosis  in 
individual  cases  are  as  follows: 

1.  Heredity:  If  the  patient's  father  or  mother  has  been 
through  such  an  illness  and  has  shown  a  tendency  to  weather 
the  storm  and  cling  to  life,  the  patient  is  apt  to  follow  a  similar 
course.  The  texture  and  workings  of  the  cardiovascular  tissues 
seem  to  me  the  most  clearly  inherited  of  all  physical  facts. 

2.  Other  things  being  equal,  the  age  of  the  patient  is  of 
importance.  Those  who  are  overtaken  by  their  malady  be- 
tween the  fortieth  and  fiftieth  year  usually  live  longer  than 
those  whose  symptoms  begin  after  fifty,  provided  always  the 
kidney  shows  no  extensive  or  permanent  lesion. 

3.  As  in  most  chronic  diseases  the  patient's  ability  and 
willingness  to  submit  to  proper  treatment  is  a  factor  of  the 


DISEASES    OF   THE    CIRCULATION.  1 67 

greatest  importance  in  the  prognosis.  This  abiHty  concerns 
in  the  first  place  his  financial  resources.  The  person  who 
must  go  on  trying  to  practice  a  calHng  that  demands  severe 
muscular  work,  the  alternative  being  starvation  or  the  alms- 
house, is  obviously  doomed  to  a  short  and  painful  illness. 
On  the  other  hand,  some  patients  are  affected  fully  as  much 
for  good  or  for  evil  by  their  temperaments  as  by  their  finan- 
cial circumstances.  The  man  who  is  unable  to  give  up  his 
responsibilities  and  his  business  engagements  without  falling 
into  depression  and  loneliness,  will  often  beat  his  life  out  in 
fruitless  endeavors  to  find  some  satisfactory  occupation  other 
than  business, 

4.  The  habits  relating  to  alcohol  and  tobacco,  especially 
to  the  former,  are  of  importance  here  as  with  all  chronic 
diseases.  Those  who  are  unable  or  unwilling  to  give  up  the 
use  of  alcoholic  stimulants  usually  succumb  much  faster  than 
total  abstainers  or  those  who  can  easily  control  themselves. 

5.  The  degree  of  cardiac  hypertrophy,  as  shown  by  the 
position  of  the  apex  beat  and  the  height  of  the  systolic  blood 
pressure,  is  directly  proportional  to  the  severity  of  the  disease. 
Other  things  being  equal,  the  higher  the  blood  pressure  the 
shorter  the  duration  of  the  illness. 

Treatment:  Two  opposite  dangers  are  to  be  avoided.  We 
may  overwork  the  patient's  heart  by  allowing  him  to  attempt 
tasks  which  overstrain  his  mind  or  his  body,  or,  on  the  other 
hand,  we  may  disturb,  through  enforced  inactivity,  that 
balance  and  compensation  already  worked  out  by  nature. 
Absolute  rest  is  a  positive  danger  in  many  cases.  The  tone 
and  sufficiency  of  the  cardiac  muscle  is  dependent  upon  a 
certain  amount  of  exercise  for  its  optimum  condition.  Just 
as  baths  and  passive  motion  may  improve  a  faulty  compensa- 
tion, so  the  lack  of  any  such  demands  upon  the  cardiac  muscle 
may  seriously  weaken  it.  I  have  seen  many  a  patient  go 
straight  down  hill  after  being  put  to  bed.  I  do  not  believe 
that  this  is  a  coincidence  in  all  the  cases  that  I  have  observed. 

By  careful  observation  and  experiment,  therefore,  we  should 
try  to  determine  how  much  exercise  of  mind  and  body  is 
sufficient  to  keep  up  the  heart's  tone  without  overstraining 
that  organ.     Unless  there  is  marked  dropsy  and  dyspnoea 


1 68  CASE   HISTORIES   IN   MEDICINE. 

on  very  slight  exercise,  no  patient  should  be  put  absolutely 
at  rest.  Even  the  slighter  degrees  of  dropsy  are  sometimes 
benefited  by  moderate  exercise.  Some  patients  can  row  or 
paddle  with  much  more  ease  than  they  can  walk,  and  if  it  is 
possible  this  form  of  exercise  may  be  distinctly  beneficial. 
Very  few  patients  in  this  class  are  benefited  by  hydrothera- 
peutics  or  passive  motion.  They  should  be  strongly  advised 
against  a  trip  to  Nauheim  or  any  of  the  other  "  cures." 

It  is  often  best  to  teach  the  patient  to  sleep  in  a  chair  with- 
out attempting  to  go  to  bed.  Sometimes  a  portion  of  the 
night  may  be  passed  in  bed,  provided  acute  dyspnoea  is  never 
called  out  by  the  attempt  to  lie  down  in  the  hours  before  rnid- 
night.     Hypnotics  have  no  value  in  insomnia  of  this  type. 

As  regards  diet,  the  important  points  are  to  avoid  over- 
distention  of  the  stomach  and  especially  irritating  substances. 
As  a  rule  the  patient  may  eat  a  small  quantity  of  any  of  the 
ordinary  types  of  food.  Meat  should  be  used  very  sparingly 
and  if  there  is  much  oedema  a  trial  of  salt-free  diet  may  be 
made. 

As  regards  medication  it  is  best  to  treat  all  the  physical 
causes  with  a  course  of  purgatives  and  diuretics  before  any 
cardiac  stimulation  is  attempted.  The  method  of  giving  such 
medication  has  been  already  described  on  page  147.  When 
cardiac  stimulants  are  begun  they  may  be  used  exactly  as  in 
the  primary  valvular  diseases  of  the  heart  although  we  have 
far  less  reason  to  be  hopeful  as  to  their  efficiency.  I  have 
seen  no  benefit  from  nitroglycerin  or  the  other  nitrites,  except 
of  course  in  cases  complicated  by  angina  pectoris. 


DISEASES   OF  THE   CIRCULATION.  1 69 

Case  61.  A  woman  of  forty-one,  with  good  family  his- 
tory, has  been  married  twice.  The  cause  of  the  death  of  her 
first  husband  is  unknown.  During  her  first  marriage  she  had 
two  miscarriages.  By  her  second  husband,  who  appears 
healthy,  she  has  never  been  pregnant.  She  has  no  rheumatic 
history.  For  ten  years  she  has  not  been  able  to  walk  far 
without  dyspnoea,  but  her  health  was  good  until  seven  years 
ago,  when  at  Carlsbad  she  took  several  baths,  and  just  after 
the  last  a  sudden  hemiplegia  developed.  For  four  months 
she  could  not  be  moved,  and  the  left  arm  and  leg,  though 
useful,  have  never  regained  full  power.  She  has  always  risen 
once  in  the  night  to  urinate.  Yesterday  she  was  as  well  as 
usual.  She  wakened  her  husband  about  i  a.m.  to-day,  and 
again,  later,  spoke  to  him.  By  4  a.m.  she  was  semi-con- 
scious, could  not  speak,  and  had  a  right  hemiparesis,  most 
marked  in  the  face. 

Next  morning  the  color  and  nutrition  were  good,  the  face 
not  flushed,  respiration  easy,  the  breath  free  from  odor.  The 
tongue  was  slowly  protruded  on  demand,  but  her  comprehen- 
sion was  much  limited.  Temperature  normal.  The  radial 
pulse  could  not  be  counted:  the  apex  beat  was  sometimes 
44,  again  72  per  minute.  The  first  apex  sound  was  exces- 
sively sharp,  the  pulmonic  second  accentuated.  No  mur- 
murs, no  thrill.  The  heart  did  not  seem  enlarged.  Com- 
plete aphasia  and  inability  to  swallow.  She  moved  the  right 
arm  somewhat,  the  right  leg  a  very  little.  Contractures  of 
the  left  fingers.  The  superficial  reflexes  were  absent ;  no  deep 
reflexes  in  the  right  arm  or  left  leg;  knee-jerk  present  on 
right.  Abdomen  negative.  The  urine  was  1012^  in  spe- 
cific gravity,  pale,  with  a  slight  trace  of  albumin,  no  sugar, 
a  few  hyalin  and  fine  granular  casts. 

1.  Types  of  facial  paralysis?     Central  paralysis,  usually  ap- 

pearing as  part  of  hemiplegia;  aural  paralysis,  occurring 
in  cases  of  well-marked  ear  disease;  and  peripheral 
paralysis,  occurring  without  any  other  lesion. 

2.  What  odors  in  the  breath  are  of  diagnostic  or  prognostic 

value?  Those  of  alcohol,  acetone,  and  illuminating  gas 
in  diagnosis;  the  foul,  heavy  odor  of  many  serious  dis- 
eases in  prognosis. 


170  CASE   HISTORIES   IN   MEDICINE. 

Diagnosis:  The  sharp  first  sound,  accented  pulmonic  sec- 
ond with  chronic  dyspnoea  and  two  attacks  of  hemiplegia 
point  to  mitral  stenosis  and  cerebral  embolism.  The  presys- 
tolic murmur  has  disappeared  owing  to  cardiac  weakness. 
Cerebral  syphilis  is  suggested  only  by  the  history  of  mis- 
carriage. 

Prognosis:  She  may  live  years,  but  the  paralysis  is  not 
likely  to  be  recovered  from  wholly. 

Treatment:  (see  Case  62). 


DISEASES   OF   THE   CIRCULATION.  I7I 

Case  62.  Patient  a  man  fifty- five  years  old;  rather  fat; 
subject  to  frequent  attacks  of  winter  cough,  with  asthmatic 
tendency.  For  seven  years  the  heart  had  been  noticeably 
weak  and  irregular.  Pulse  80;  first  sound  valvular.  Apex 
beat  an  inch  and  a  half  directly  below  left  nipple;  no  mur- 
murs. No  previous  rheumatism.  Several  years  ago  there 
was  sudden  and  complete  loss  of  memory,  the  same  questions 
being  repeated  as  soon  as  answered.  The  expression  was  at 
the  time  rather  vacant;  the  pupils  were  equal  and  responded 
to  light;  there  was  no  motor  paralysis.  The  amnesia  lasted 
all  day,  disappearing  the  following  morning.  The  pulse  re- 
mained 50  for  two  days.  The  patient  had  been  previously 
very  anaemic,  and  had  had  much  fatigue  and  anxiety,  with 
digestive  disturbance.  The  urine  always  remained  normal. 
In  the  following  years  there  were  occasional  attacks  of  tran- 
sient numbness  in  the  left  arm  and  leg,  and  sometimes  faint 
turns  with  pallor  and  irregular,  feeble  pulse.  Headache  was 
a  frequent  symptom;  dyspnoea  on  exertion,  impaired  appetite, 
and  insomnia  were  constant.  There  was  no  apparent  loss  of 
flesh.  In  1897  life  was  endangered  for  two  weeks  by  oedema 
of  both  lungs,  supervening  on  an  attack  of  bronchitis.  In 
the  subsequent  years  the  condition  improved  somewhat,  so 
that  the  patient  could  walk  half  a  mile  or  more  and  was  able 
to  attend  to  considerable  business.  In  autumn  of  1904,  he 
had  several  attacks  of  bronchitis,  and,  finally,  an  attack  of 
complete  hemiplegia  resulted  fatally  in  twenty-four  hours 
without  recovery  of  consciousness.  Respiration  was  of  the 
Cheyne-Stokes  type,  and  later  stertorous. 

1 .  Significance  of  stertorous  respiration  ?     Any  deep  coma 

(even  deep,  healthy  sleep)  may  produce  it. 

2.  What  is  meant  by  an  asthmatic  tendency  —  i.e.,  on  what 

physical  signs  should  such  a  diagnosis  be  based? 
Squeaking  and  groaning  rales  present  on  slight  exer- 
tion or  ^excitement,  with  or  without  typical  asthmatic 
paroxysms  at  long  intervals. 

3.  What  are  the  relations  of  bronchitis  and  other  pulmonary 

lesions  to  disease  of  the  heart?  (a)  Chronic  bronchitis 
may  lead  to  emphysema,  and  this  to  hypertrophy, 
dilatation  and  weakening  of  the  right  ventricle  with 
tricuspid   leakage,     (b)   Mitral   disease   may   favor   the 


172  CASE   HISTORIES   IN   MEDICINE. 

occurrence  of  bronchitis  and  pneumonia  of  various 
types.  Intracardiac  thrombosis,  occurring  in  weakened 
conditions  of  the  heart  from  valvular  or  m.yocardial 
disease,  may  result  in  pulmonary  embolism.  Septic  or 
bland  emboli  are  occasionally  washed  into  the  lungs 
from  vegetations  on  the  tricuspid  valve.  The  rare 
lesions  of  the  pulmonary  valves  involve  malnutrition 
of  the  lungs  and  (in  one  case  known  to  me)  frequent 
attacks  of  pneumonia.  Phthisis  and  endocarditis  rarely 
coexist. 


Diagnosis:  The  brain  and  heart  seem  to  be  the  organs 
chiefly  affected.  In  a  man  of  fifty- five,  weak,  irregular  heart 
and  pulse,  with  dyspnoea  on  exertion,  but  without  murmurs, 
are  usually  explained  as  results  of  coronary  sclerosis  and 
myocarditis.  The  "  asthmatic  tendency,"  obstructing  the 
pulmonary  circulation  and  so  increasing  the  work  of  the  right 
ventricle,  probably  contributed  to  weaken  the  heart.  The 
acme  of  cardiac  weakness  caused  the  pulmonary  oedema  in 
T897.  The  amnesia  with  bradycardia,  the  hemiparsesthesia 
and  faint  turns,  and  the  terminal  coma  of  hemiplegia,  are 
results  of  cerebral  arteriosclerosis  with  final  haemorrhage. 
No  other  diagnosis  is  plausible,  provided  the  urine  remained 
normal  and  provided  syphilis  can  be  excluded. 

The  prognosis  and  treatment  of  the  underlying  arterio- 
sclerosis have  already  been  described  (see  pages  166  and  167). 
Here  only  the  complicating  apoplexy  will  be  considered. 

Prognosis:  Most  patients  recover  from  their  first  attack 
of  apoplexy.  It  is  usually  the  second  or  the  third  shock 
which  is  fatal.  Favorable  indications  are  the  early  recovery 
of  consciousness  or,  better  still,  the  failure  altogether  to  lose 
consciousness,  an  early  disappearance  of  the  severest  para- 
lytic symptoms,  a  relatively  low  blood  pressure,  and  the 
absence  of  renal  or  peripheral  complications.  The  patients 
may  live  and  work  for  five  or  ten  years  after  their  first  attack 
of  apoplexy,  provided  the  heart  and  kidney  are  in  fairly 
good  condition.  As  a  rule,  however,  the  second  shock 
follows  the  first  within  one  or  two  years  and  is  apt  to  be 
more  severe.  I  am  referring  of  course  throughout  to  the 
apoplexies   resulting   from   arteriosclerosis   in   elderly   people 


DISEASES   OF   THE   CIRCULATION.  1 73 

whether  it  be  due  to  haemorrhage,  to  thrombosis,  embolism, 
or  vascular  crisis. 

Treatment:  The  main  thing  is  to  avoid  doing  harm.  I 
have  seen  patients  almost  choked  to  death  by  unwise  at- 
tempts to  feed  them.  There  is  no  danger  that  such  a  patient 
will  starve  before  he  recovers  consciousness.  If  the  mouth 
is  very  dry,  normal  saline  solution  may  be  injected  under  the 
skin  or  into  a  vein.  The  use  of  cathartics  does  not  seem  to 
me  of  any  great  value,  but  doubtless  it  does  something  to 
lower  blood  pressure.  The  same  effect,  however,  can  be 
better  accomplished  by  venesection,  which  is  to  be  recom- 
mended in  all  plethoric  patients  with  very  high  blood  pressure. 
As  a  rule  there  is  no  need  of  cardiac  stimulation.  Care  must 
be  taken  to  prevent  bed-sores,  and  the  patient  may  often  need 
to  be  catheterized. 

After  the  patient  regains  consciousness  the  accompanying 
paralysis  is  best  treated  by  encouraging  the  patient  in  every 
possible  way  to  use  all  the  power  that  he  has  got.  Other 
methods  of  treatment  such  as  electricity  and  the  use  o.- 
Zander  apparatus  are  of  value  chiefly  because  they  help  to 
keep  up  the  patient's  courage  and  stimulate  his  efforts  at 
voluntary  motion.  Of  course  if  there  is  any  well-grounded 
suspicion  of  a  syphilitic  disease  in  the  background,  mercury 
and  iodid  of  potash  should  be  given  in  the  usual  way. 


174  CASE   HISTORIES   IN    MEDICINE. 

Case  63.  A  sub-freshman  of  seventeen  of  an  extraordi- 
narily nervous  temperament,  six  feet  two  inches  high,  con- 
sulted me  May  12,  1910,  in  company  with  his  still  more 
nervous  mother.  All  through  the  previous  fall  and  winter 
he  was  very  active  in  competitive  athletics,  including  sprint- 
ing, swimming,  and  tennis.  He  is  now  working  hard  for  his 
final  examination  for  entrance  to  college. 

Four  weeks  ago  he  was  examined  by  a  physician  who  told 
him  that  his  heart  was  enlarged  and  showed  murmurs.  Fol- 
lowing this  yerdict  he  became  excessively  alarmed  about  him- 
self and  began  for  the  first  time  to  suffer  from  palpitation. 
He  at  once  took  to  bed  and  remained  there  until  April  22, 
when  he  was  moved  to  Atlantic  City.  There  he  has  remained 
until  to-day,  doing  practically  no  walking,  sleeping  and  eat- 
ing poorly,  and  still  very  conscious  of  the  irregularity  of  his 
heart. 

On  examination  the  heartbeat  was  excessively  rapid  and 
violent  but  quite  regular.  Its  rapidity  the  patient  explained 
as  being  due  to  the  fact  that  he  was  being  examined.  The 
apex  impulse  was  diffuse  and  wavy.  By  percussion  it 
appeared  to  extend  an  inch  and  a  half  outside  the  nipple 
line  in  the  fifth  interspace.  By  sight  and  touch  it  seemed  to 
be  even  more  displaced.  The  sounds  were  loud  and  clear. 
No  murmurs  or  accentuation  were  audible.  The  blood  pres- 
sure was  from  165  to  175  mm.  Hg.  The  pulse  and  arte- 
rial walls  not  remarkable.  The  patient  moved  about  easily 
without  dyspnoea  and  was  equally  comfortable  in  the  recum- 
bent and  in  the  upright  positions.  There  was  no  oedema 
in  the  lungs  or  elsewhere,  and  physical  examination,  save 
as  above  noted,  was  wholly  negative.  The  urine  amounted 
to  60  ounces  in  twenty-four  hours,  specific  gravity  1013,  no 
albumin,  no  sugar.  Blood  was  negative.  Temperature  con- 
stantly normal. 

On  further  questioning  it  was  ascertained  that  from  March 
10  to  March  30  the  patient  had  been  having  scarlet  fever  and 
that  at  the  end  of  this  attack  his  pulse  was  noted  to  be  some- 
what irregular. 

Diagnosis:  Cardiac  overstrain  due  to  excessive  muscular 
effort  in  athletics,  myocardial  weakness  with  dilatation  and 


DISEASES   OF   THE   CIRCULATION.  175 

hypertrophy  following  scarlet  fever,  and  chronic  glomerulo- 
nephritis with  resulting  cardiac  enlargement  and  weakness 
are  the  chief  possibilities  to  be  considered  in  this  case. 

As  regards  the  first  of  these  —  a  so-called  athlete's  heart  — 
we  must  note  that  the  period  of  overstrain  coincided  with  the 
period  of  very  rapid  growth  and  hard  study.  On  the  other 
hand,  it  is  notable  that  he  experienced  no  discomforts  of  any 
kind  during  or  soon  after  the  period  of  excessive  exertion. 
In  favor  of  a  post-scarlet  fever  myocarditis  is  the  close  se- 
quence of  the  symptoms  upon  that  disease  which,  as  is  well 
known,  is  prone  to  attack  the  heart  as  well  as  the  kidney, 
although  cardiac  complications  are  much  commoner  in 
diphtheria. 

Of  nephritis  we  have  no  direct  evidence.  Nothing  of  the 
kind  was  noticed  either  during  or  after  his  scarlet  fever.  His 
urine  is  quite  consistent  with  the  diagnosis  of  secondary  con- 
tracted kidney  (chronic  glomerulonephritis)  but  it  is  also  just 
what  one  would  expect  in  an  excessively  neurotic  boy  who 
was  frightened  about  himself  and  his  heart. 

Leaving  all  these  questions  for  the  moment  undecided,  let 
us  ask  whether  we  may  be  dealing  with  a  purely  neurotic  type 
of  heart  trouble.  This  is  suggested  by  the  immediate  se- 
quence of  his  most  distressing  symptoms  upon  the  doctor's 
discovery  of  heart  trouble  previously  unknown.  It  was 
further  supported  by  the  fact  that  he  immediately  improved 
under  the  encouragement  which  I  felt  justified  in  giving  him. 
Nevertheless  it  seems  to  me  impossible  to  explain  the  in- 
creased area  of  cardiac  dulness  and  the  notably  elevated 
blood  pressure  as  the  result  of  ^  neurosis. 

On  the  whole  it  seems  to  be  most  likely  that  the  scarlet 
fever  poison  was  the  cause  of  his  troubles.  Its  effect  was 
exerted,  presumably,  upon  the  myocardium  since  there  are 
no  evidences  either  of  endocarditis  or  pericarditis. 

Prognosis  and  Treatment:  The  majority  of  such  cases  show 
very  notable  and  permanent  improvement  after  a  long  period 
of  rest  followed  by  the  gradual  resumption  of  muscular 
activities  in  a  graduated  scale.  Under  such  treatment  he 
rapidly  improved  until  on  October  25,  1910,  the  cardiac  apex 
had  receded  to  a  point  half  an  inch  outside  the  nipple  while 


176  CASE  HISTORIES   IN  MEDICINE. 

the  blood  pressure  had  fallen  to  150.  By  this  time  he  was 
walking  three  or  four  miles  a  day  and  doing  more  than  the 
average  amount  of  college  work  without  any  symptoms  of 
any  kind.     No  drugs  were  given. 


DISEASES   OF   THE   CIRCULATION.  1 77 

Case  64.  A  bank  president,  seventy-four  years  old,  of 
large  frame,  lost  his  father  at  sixty-four  from  apoplexy,  his 
mother  at  about  the  same  age  from  phthisis.  Several  of  his 
sisters  also  died  of  phthisis.  His  health  has  been  exception- 
ally good,  and  a  daughter  cannot  remember  his  having  taken 
to  his  bed  before.  During  the  past  year  his  weight  has  grad- 
ually fallen  from  240  to  perhaps  190  pounds.  His  color  has 
been  poor  occasionally,  and  it  has  been  noticed  that  a  sudden 
pull  on  the  part  of  his  horses  while  driving  would  make  him 
cry  out,  "  Oh!  my  stomach!  "  He  has  not  been  able  to  walk 
as  much  as  formerly  on  account  of  pain  in  the  back  and  dysp- 
noea. He  has  also  had  sleepy  turns,  even  after  breakfast, 
for  a  year  or  more.  About  four  weeks  ago,  walking  up  a 
slight  incline  after  a  concert,  he  lost  his  breath  and  had  to 
stop  six  times  on  his  way  home,  even  after  he  reached  level 
"ground.  December  25  he  sent  for  his  physician  for  a  "  catar- 
rhal cold."  The  pulse  was  38,  regular,  the  temperature  sub- 
normal; there  was  some  oedema  and  eczema  of  the  legs,  and 
moist  rales  over  the  base  of  both  lungs,  without  notable  dul- 
ness  or  change  in  the  quality  of  the  respiratory  murmur.  He 
stayed  indoors  and  three  days  later  took  to  his  bed.  Very 
soon  after  this  he  had  frothy,  profuse,  and  thin,  pink  expecto- 
ration, with  somewhat  labored  but  not  quickened  respiration. 
The  slow  pulse  persisted.  The  urine  was  about  a  quart  in 
twenty-four  hours,  normal  in  specific  gravity,  with  hyalin 
and  finely  granular  casts. 

January  13  he  was  seen  in  consultation.  His  chief  com- 
plaint was  of  weakness  and  anorexia.  Digestion  fair,  bowels 
regular;  practically  no  cough  or  expectoration.  Most  of  the 
time  is  passed  in  sleep.  He  lies  by  preference  on  the  right 
side,  with  the  head  low.  He  looks  less  than  his  age ;  the  lips 
are  slightly  cyanotic,  the  respiration  easy,  the  tongue  moist 
and  clean,  the  mind  clear  when  awake.  The  pulse  is  38, 
regular,  synchronous  with  the  apex  beat.  During  the  last 
fortnight  it  has  never  been  found  above  40,  and  has  been 
counted  at  24.  The  radial  arteries  are  slightly  degenerated. 
The  cardiac  impulse  is  in  the  fifth  space,  nearly  an  inch  be- 
yond the  left  nipple  ;'dulness  seems  rather  increased  to  the 
right.     Systolic  murmurs  are  heard  in  both  the  aortic  and 


178  CASE   HISTORIES   IN   MEDICINE. 

mitral  areas,  and  the  second  sound  is  reduplicated  at  the  apex. 
The  lungs  are  clear.  There  is  dulness  below  the  right  costal 
border,  but  palpation  gives  negative  results  in  that  region. 
Beyond  slight  oedema  of  the  feet,  physical  examination  is 
otherwise  practically  negative. 

1.  Common  causes  of  loss  of  weight?     Improper  or  insuffi- 

cient diet,  diarrhoea,  arteriosclerosis,  and  the  attendant 
changes  of  old  age,  loss  of  sleep,  malignant  disease. 

2.  Causes  of  bradycardia?     It  is  important  to  distinguish 

infrequent  heartbeat  from  infrequent  pulsebeat  due  to 
failure  of  transmission  of  a  weakened  cardiac  impulse. 
True  bradycardia  occurs  after  fevers,  great  exertion, 
parturition,  in  the  toxaemia  of  nephritis,  cirrhosis,  and 
jaundice,  in  organic  brain  disease  (tumor,  abscess,  men- 
ingitis). The  most  marked  and  long  continued  cases  of 
bradycardia  are  usually  associated  with  coronary  scle- 
rosis and  myocarditis. 

3.  How  is  the  frothy,  pink  expectoration  to  be  explained  in 

view  of  the  fact  that  at  a  later  examination  the  lungs 
were  clear?  Frothy,  pink  expectoration  with  labored 
respiration  is  in  all  probability  due  to  pulmonary  oedema. 
This  condition  may  be  temporarily  produced  and  ar- 
rested by  unknown  causes,  and  thus  at  a  later  examina- 
tion may  be  wholly  absent. 

4.  What  is  to  be  suspected  when  epigastric  pain  seems  to 

be  brought  on  (as  in  this  case)  by  exertion?  Angina 
pectoris. 

5.  What  physical  signs  should  be  looked  for  in  the  neck  in 

this  case?  Jugular  pulsation  at  a  rate  twice  or  thrice 
that  of  the  radial  pulse.  This  was  unfortunately  not 
recorded  in  this  case. 

Diagnosis:  In  a  man  of  seventy-four,  with  symptoms  dis- 
tinctly suggesting  angina  pectoris,  the  association  of  sleepy 
turns  and  a  pulse  between  24  and  38  means  in  all  probability 
Stokes-Adams  syndrome  with  coronary  sclerosis  even  though 
we  have  not  evidence  regarding  the  auricular  systole.  The 
dyspnoea,  the  "  catarrhal  cold,"  the  later  attack  of  pulmonary 
oedema,  the  urinary  and  digestive  symptoms,  and  the  slight 
oedema  of  the  feet  are  all  to  be  explained  as  results  of  myo- 
cardial weakness.  The  loss  of  weight  is  probably  due  to 
arteriosclerosis. 


DISEASES   OF   THE    CIRCULATION.  1 79 

Prognosis:  Nothing  is  more  difficult  than  to  state  the 
probable  duration  of  life  in  such  a  case.  Recovery  is  impos- 
sible and  death  may  occur  at  any  time,  yet  life  may  be  pro- 
longed and  considerable  comfort  secured  for  months  or  years. 

Treatment:  Restriction  of  activity,  mental  and  physical, 
good  hygiene,  limitation  of  sodium  chloride  in  the  diet,  and 
the  administration  of  KI  and  nitroglycerin  in  small  doses  are 
the  chief  indications.    For  further  detail  see  Case  59. 


l80  CASE   HISTORIES   IN   MEDICINE. 

Case  65.  A  prominent  manufacturer,  sixty-two,  of  good 
habits  and  family  history.  Never  previously  sick.  Has  been 
much  confined  for  a  year  and  weight  has  increased  from  164 
to  174  pounds.     Was  seen  February  15. 

Shortly  before  Christmas  he  noticed  shortness  of  breath  on 
walking.  His  urine  at  that  time  was  pronounced  negative. 
The  dyspnoea  on  exertion  got  no  better  and  substernal  pain 
extending  over  the  arms  was  soon  superadded.  This  pain 
was  not  very  severe,  and  came  on  only  during  exertion. 
About  two  weeks  ago,  after  a  hearty,  rapid,  and  rather  indi- 
gestible midday  dinner,  he  was  taken  at  his  mill,  without  an- 
tecedent exertion,  with  a  very  severe  attack  of  pain  as  above 
described.  When  his  physician  reached  him  he  was  in  a  cold 
sweat  and  seemed  alarmingly  ill.  Pulse  80,  regular.  After 
two  hours  he  was  driven  home  four  miles,  arriving  with  pulse 
at  80  and  temperature  at  97.5°.  The  next  day  the  pulse 
was  100,  temperature  100°,  rising  to  (^^  and  102°  the  next 
day.  There  was  bloody  expectoration,  with  signs  of  consoli- 
dation at  the  right  posterior  base.  For  the  past  week  the 
pulse  and  temperature  have  been  normal.  When  seen  Feb- 
ruary 15  he  stated  that  he  felt  perfectly  well.  He  looked 
rather  pale,  lay  in  bed  with  his  head  low,  breathing  easily, 
not  cyanotic.  The  pulse  80,  intermitted  occasionally.  The 
artery  was  soft,  tension  not  high.  No  oedema.  The  heart 
was  not  enlarged;  sounds  clear.  A  few  rales  without  dulness 
over  the  left  posterior  base.  Percussion  was  dull  with  re- 
sistance an  inch  below  the  right  costal  border,  but  the  liver 
edge  could  not  be  felt.  The  urine,  52  to  54  ounces  per  diem, 
contained  a  decided  trace  of  albumin  and  a  few  hyalin  casts, 
specific  gravity  1020,  urea  2%. 

1.  What   diseases   increase   weight?     Obesity,    cardiac   and 

renal  disease,  myxcedema. 

2.  Causes  of  bloody  expectoration  ?     Phthisis,   pneumonia, 

infarction  of  the  lung  due  to  congestion  (as  in  mitral 
disease  or  from  embolism),  pulmonary  abscess  or  gan- 
grene, wounds  or  malignant  disease  of  the  lung,  rup- 
tured oesophageal  varices  (in  cirrhotic  liver),  leaking 
aneurism. 


DISEASES   OF   THE   CIRCULATION.  l8l 

Diagnosis:  In  a  man  of  sixty-two,  dyspnoea  and  substernal 
pain  produced  by  exertion,  extending  to  the  arms  and  re- 
lieved by  stopping,  are  symptoms  almost  pathognomonic  of 
coronary  sclerosis  with  angina  pectoris.  The  pain  of  aneu- 
rism is  somewhat  similar,  but  has  not  the  close  dependence 
on  exertion.  The  severe  attack  two  weeks  ago  seems  to 
have  ended  in  pulmonary  congestion  and  hypostatic  pneu- 
monia. The  examination  of  February  15  adds  only  the  evi- 
dence of  an  arteriosclerotic  kidney.  It  is  surprising  that 
arterial  tension  appears  low.  Was  the  aortic  second  accen- 
tuated ? 

Only  the  prognosis  and  treatment  of  angina  pectoris  will 
be  considered  here.  For  treatment  of  the  other  elements  in 
the  clinical  picture  see  Cases  57,  58,  59,  and  62. 

Prognosis:  It  is  no  longer  possible  sharply  to  distinguish 
the  organic  from  the  functional  cases  of  angina  pectoris. 
The  so-called  functional  cases  usually  occur  in  younger  people 
and  have  a  distinctly  better  prognosis.  As  a  rule  the  more 
widespread  and  constant  the  pain,  the  less  ominous  it  is. 
The  most  serious  cases  are  those  in  which  the  pain  is  sharply 
localized  to  a  circumscribed  area  which  is  the  same  in  every 
attack.  These  severe  cases  are  usually  free  from  suffering 
as  soon  as  the  acute  attack  Is  over  and  may  feel  perfectly 
w^ell  for  days  at  a  time.  On  the  other  hand,  patients  who 
complain  of  a  certain  amount  of  constant  aching  not  only 
in  the  precordia  and  left  arm  but  throughout  the  left  chest 
and  shoulder,  usually  live  much  longer  than  the  more  parox- 
ysmal cases.  Cases  of  sudden  death  are  mostly  in  patients 
who  have  relatively  few  attacks  and  feel  perfectly  well  be- 
tween them,  so  that  they  are  allowed  to  undertake  vigorous 
work.  Beyond  this  there  is  nothing  to  be  said  about  the 
prognosis  except  what  has  already  been  stated  regarding  the 
underlying  disease  of  arteriosclerosis.  In  this  as  in  all  of 
the  complications  of  arteriosclerosis,  financial  standing,  tem- 
peramental quality,  and  age  are  the  determining  factors. 

Treatment:  Obviously  one  must  try  to  reduce  the  number 
of  occasions  on  which  exertion,  emotional  excitement,  or 
sudden  change  of  position  precipitate  an  attack.  Patients 
should  be  especially  careful  when   they  first  wake  in   the 


1 82  CASE   HISTORIES   IN   MEDICINE. 

morning.  The  heart  has  to  be  gradually  accustomed  to  the 
severer  work  demanded  by  waking  life.  Nocturnal  attacks 
are  more  apt  to  come  in  those  who  attempt  to  sleep  with  the 
head  low.  Such  attacks  can  sometimes  be  warded  off  by 
sleeping  in  a  chair.  All  hill  climbing  and  stair  climbing  are 
to  be  forbidden.  On  the  other  hand,  rowing  is  often  quite 
easily  performed.  If  there  is  an  accompanying  obesity  the 
reduction  of  the  surplus  fat  may  greatly  diminish  the  number 
of  attacks  by  diminishing  the  heart's  load. 

The  patient  should  always  carry  in  his  pocket  a  box  con- 
taining either  nitroglycerin  tablets,  200"  or  yio"  grains,  or  the 
so-called  pearls  of  amyl  nitrate.  Some  patients  like  one  of 
these  preparations  much  better  than  the  other;  only  experi- 
ment can  decide  this  point,  as  well  as  the  size  of  the  dose. 

For  reasons  which  I  am  unable  to  explain,  manipulation 
of  the  precordial  tissues,  sometimes  of  the  shoulder  and  arm, 
brings  about  a  definite  improvement  in  some  patients.  A 
masseur  or  an  osteopath  sometimes  cures  or  greatly  relieves 
patients  whom  regular  practitioners  have  failed  to  help.  We 
are  much  in  need  of  further  light  in  this  direction. 


DISEASES   OF   THE   CIRCULATION.  1 83 

Case  66.  Mr.  V.,  a  theater  usher  of  forty-seven,  unmar- 
ried, lost  his  voice  six  months  ago.  Since  then  it  has 
gradually  improved  until  now  he  speaks  quite  audibly. 
Otherwise  he  has  been  well  and  worked  steadily  and  hard,  — 
though  occasionally  he  has  felt  an  ache  between  his  shoulders 
for  one-half  a  day  or  so.  On  one  occasion,  three  months  ago, 
this  pain  occurred  while  he  was  walking  and  almost  took 
his  breath  away  for  a  few  minutes.  Since  this  time  there 
has  been  no  pain.  Insomnia  has  troubled  him  for  many 
years,  and  he  gets  little  sleep  after  4  a.m.  He  admits  that 
he  is  of  nervous  temperament,  and  has  been  considerably 
worried.  There  has  been  no  cough,  no  emaciation,  and,  so 
far  as  he  knows,  no  fever.  Appetite  good,  bowels  regular. 
His  regular  weight  is  158. 

Examination  shows  a  healthy-looking  man  with  no  fever. 
Weight  160.  The  heart's  apex  in  the  fifth  space,  three- 
quarters  of  an  inch  outside  the  nipple.  The  heart  sounds 
are  clear  —  the  aortic  second  loud,  low-pitched,  and  easily 
palpable.  The  pupils  are  equal  and  react  normally.  The 
pulses  equal  and  synchronous.  Brachials  slightly  tortuous 
and  have  a  lateral  excursion.  No  thrill  or  abnormal  dulness 
in  the  front  of  the  chest. 

At  the  left  apex  behind,  there  is  dulness,  increased  voice 
and  fremitus,  and  whistling  breathing  (stridor).  In  the  right 
side  of  the  neck  is  a  mass  the  size  of  a  goose's  egg;  its  lower 
portion  is  hard  and  seems  connected  with  the  clavicle.  Above 
it  pulsates  strongly.  The  whole  is  smooth  and  not  tender. 
Laryngoscopic  examination  shows  the  left  vocal  cord  in  the  ca- 
daveric position.  The  blood  and  urine  are  normal  and  visceral 
examination  is  negative,  except  for  the  deviations  just  noted. 

1.  Causes  of  accentuated   aortic  second  sound?     Increased 

peripheral  resistance  due  to  arteriosclerosis,  nephritis 
with  high  tension  pulse,  severe  muscular  exertion, 
nervous'  excitement,  aneurism. 

2.  Causes  of  hoarseness  or  aphonia?     Laryngitis  ("  simple  " 

or  tuberculous),  syphilis,  laryngeal  tumors,  paralysis  of 
a  vocal  cord  or  partial  paralysis  of  both,  hysteria. 

3.  What  is  the  cervical  tumor  ?     It  was  at  first  diagnosed  as 

aneurism  (of  the  carotid  or  subclavian),  but  proved  to 
be  a  cervical  rib  crossed  by  the  subclavian. 


1 84  CASE   HISTORIES   IN   MEDICINE. 

Diagnosis:  The  important  signs  are:  paralysis  of  the  left 
vocal  cord,  arteriosclerosis  with  resulting  cardiac  hypertrophy, 
solidification  and  stridor  at  the  apex  of  the  left  lung.  An  X-ray 
plate  of  the  chest  showed  a  large  aneurism  of  the  aortic  arch. 
The  puzzling  things  in  the  case  were  (a)  the  pulsating  tumor  in 
the  right  neck,  which  one  tried  naturally  but  unsuccessfully  to 
associate  with  the  paralysis  of  the  left  vocal  cord,  and  {h)  the  ab- 
sence of  any  signs  of  aneurism  except  the  paralyzed  vocal  cord. 

Prognosis:  The  average  duration  of  life  is  from  two  to 
four  years.  Relapses  are  almost  Inevitable  if  temporary 
Improvement  is  secured.  Nevertheless  a  symptomatic  re- 
covery occasionally  occurs.  The  patient  must  look  forward 
to  many  months  of  inactivity  as  the  best  of  the  alternatives 
threatening  him. 

Treatment:  The  so-called  Tufnell  plan  of  management  Is 
probably  the  best  In  the  majority  of  cases.  The  aim  of  this 
regime  is  to  reduce  blood  pressure  and  promote  clotting 
within  the  sac.  The  patient  Is  put  to  bed  and  forbidden  all 
unnecessary  motions.  It  is  better  that  he  should  not  even 
feed  himself.  The  amount  of  food  Is  reduced  to  a  minimum 
and  the  intake  of  liquids  Is  also  strictly  limited.  Just  how 
far  we  are  to  carry  this  starvation  process  must  be  settled 
In  each  case  with  due  regard  to  the  patient's  powers  of 
resistance  and  of  self-control.  He  should  not  be  allowed  to 
lose  more  than  two  pounds  a  week  In  weight.  Such  a  regime 
may  be  carried  out  for  eight  or  ten  weeks;  In  exceptional 
cases  for  three  months.  It  usually  diminishes  pain  and  pro- 
motes comfort  In  all  respects.  Projecting  masses  may  dis- 
appear within  the  chest  and  the  veins  become  again  normal. 

Since  It  is  now  generally  believed  that  aneurism  is  almost 
invariably  of  syphilitic  origin.  It  Is  advisable  to  give  potassic 
lodid  and  mercury  either  during  or  following  the  carrying 
out  of  the  Tufnell  regime. 

Finally,  the  operation  of  "  wiring  "  Is  probably  applicable 
to  a  small  percentage  of  cases  in  which  the  aneurlsmal  sac 
projects  at  a  sharp  angle  from  the  main  course  of  the  aorta. 
Unfortunately  it  Is  very  difficult  to  Identify  or  to  select  such 
cases,  and  If  we  make  a  mistake  In  our  selection,  the  operation 
Is  apt  to  be  fatal.  At  present  It  can  be  mentioned  only  as  a 
last  resort  or  legal  euthanasia. 


CHAPTER  V. 

DISEASES    OF   THE    RESPIRATORY   TRACT. 

Case  67.  A  female  domestic,  twenty-nine  years  old,  single, 
lost  her  father,  a  dissipated  man,  from  phthisis.  She  herself 
was  chlorotic  five  years  ago,  but  has  been  otherwise  well.  A 
year  ago  she  took  a  severe  cold,  and  after  a  few  days  felt  a 
sudden  intense  pain  in  the  left  lower  axilla.  Cough  followed, 
with  little  or  no  sputa.  She  was  not  long  laid  up,  but  has 
been  short  of  breath  on  exertion  ever  since.  She  denies  per- 
sistent cough,  and  states  that  it  is  present  only  when  she  takes 
cold:  expectoration  at  these  times  is  scanty,  but  has  several 
times  been  blood-streaked.  She  thinks  she  has  lost  no  flesh 
and  has  not  been  feverish.  She  has  been  and  is  now  steadily 
at  work.  Her  employer  sends  her  to  be  looked  at  while  the 
physician  is  visiting  a  member  of  the  family. 

The  general  appearance  is  that  of  health;  pulse  and  tem- 
perature normal.  She  complains  only  of  dyspnoea  on  exer- 
tion, dry  cough,  and  anorexia.  The  chest  is  symmetrical; 
the  interspaces  are  well  defined ;  no  cardiac  impulse  is  visible ; 
the  left  chest  dilates  less  than  the  right.  The  heart  sounds 
are  loudest,  and  the  impulse  best  felt  just  below  the  ensiform 
cartilage;  the  sounds  are  normal.  The  cardiac  dulness  seems 
to  extend  farther  than  usual  to  the  right  of  the  sternum.  The 
right  chest  is  hyperresonant  throughout,  with  puerile  respira- 
tion. The  left  chest,  including  the  cardiac  area,  is  tympanitic 
with  very  feeble  respiration  and  absence  of  vocal  fremitus. 
In  the  left  lower  axilla  there  is  faint,  amphoric  breathing. 

1.  What  pulmonary  diseases  cause  pain?     Pleurisy  ("  sim- 

ple," tuberculous,  or  pneumonic),  malignant  disease. 

2.  Significance  of  bloody  sputa?     If  blood  appears  in  streaks 

it  is  usually  from  the  throat  (pharyngitis).     In  phthisis 
blood  is  usually  in  larger  amount. 

3.  What  do  you  infer  from  the  fact  that  this  patient  has  not 

felt  sick  enough  to  disable  her  from  work  and  has  the 


1 86  CASE   HISTORIES   IN   MEDICINE. 

appearance  of  health?  The  disease,  whatever  it  is, 
must  be  producing  chiefly  local,  not  constitutional, 
effects. 

4.  Under  what  conditions  is   the  cardiac  impulse  absent? 

Thick  chest  walls  or  emphysema  may  hide  the  heart; 
pleural  effusion,  pneumothorax,  or  adhesions  may  dis- 
place it  behind  the  sternum.  Its  beat  may  be  too  weak 
to  feel. 

5.  In  what  diseases  may  cardiac  dulness  extend  more  than 

2  cm.  beyond  the  right  sternal  margin  ?  Whenever  the 
right  heart  is  distended,  and  whenever  the  heart  is  dis- 
placed to  the  right  from  any  cause. 

6.  Significance  of  puerile  respiration?     Extra  work  done  by 

the  lung. 

7.  What  changes  in  the  blood  and  urine  do  you  expect  in  this 

case?  Normal  blood,  possibly  a  slight  leucocytosis. 
Probably  normal  urine;  possibly  albuminuria  and  a  few 
casts. 

Diagnosis:  Succussion  produced  a  loud  splash.  Pneumo- 
hydrothorax  was  obvious,  probably  of  tuberculous  origin. 
The  latency  of  symptoms  is  surprising  but  not  unprecedented. 
Bacilli  were  later  found  in  the  sputa. 

Prognosis:  The  prognosis  Is  essentially  that  of  phthisis, 
though  the  complicating  pneumohydrothorax  makes  the  out- 
look somewhat  less  favorable.  Since  the  amount  of  air  in 
the  chest  is  not  enough  to  depress  the  heart  or  produce  any 
pain  or  dyspnoea,  there  seems  no  good  reason  to  interfere 
with  it  by  tapping.  Presumably  it  will  later  be  absorbed  if 
the  patient's  general  condition  can  be  improved. 

Treatment:  That  of  phthisis,  as  already  described  on 
page  24. 


DISEASES   OF   THE   RESPIRATORY   TRACT.  187 

Case  68.  A  paper  hanger,  forty-five  years  old,  is  seen  May 
17.  His  history  obtained  from  the  attending  physician,  who 
made  his  first  call  May  3,  was  as  follows:  The  patient  uses 
alcohol  in  moderation,  and  has  had  no  previous  illness.  April 
27  he  had  a  chill  followed  by  sharp  pain  in  the  lower  right 
chest,  some  cough  with  bloody  expectoration,  and  shortness 
of  breath.  He  has  been  in  bed  ever  since.  On  May  3  the 
right  chest  was  dull  below  the  fourth  rib  in  front  and  below 
midscapula  behind,  with  bronchovesicular  respiration,  in- 
creased voice,  and  vocal  fremitus.  The  cardiac  apex  was  in 
the  fifth  space  just  outside  the  nipple  line.  No  murmurs. 
The  second  pulmonic  sound  was  accentuated.  The  tempera- 
ture ran  between  101°  and  102.5°  until  the  morning  of  May  8, 
when  it  fell  to  99°.  Since  then  it  has  been  irregular,  varying 
between  100°  and  102°.  The  respiration  was  35  until  the 
8th,  when  it  fell  to  28,  where  it  has  since  remained.  The 
pulse  has  varied  between  100  and  no.  Urine  negative. 
The  patient  has  lost  strength  and  weight.  The  signs  in  the 
lungs  have  gradually  changed ;  now  the  right  chest  seems  fuller 
than  the  left  and  moves  but  little  with  respiration.  It  is  flat 
throughout  on  percussion,  with  diminished  vocal  resonance 
and  fremitus.  Respiration  is  bronchial  down  to  the  fifth  rib 
in  front,  growing  gradually  feebler  below  that  point  until  it 
is  lost  toward  the  base.  Feeble  bronchial  respiration  is  heard 
over  the  back,  with  numerous  medium  moist  rales  at  the  angle 
of  scapula.  The  heart  remains  as  before.  The  smooth  edge 
of  the  liver  is  felt  two  inches  below  the  costal  margin.  White 
cells,  28,000. 

A  needle  was  introduced  on  the  14th  in  the  eighth  inter- 
space In  the  posterior  axillary  line,  and  again  to-day  an  inch 
or  two  farther  back.  It  appeared  to  enter  a  solid  body,  and 
only  a  drop  or  two  of  blood  was  obtained. 

1.  In   what   diseases   is   bronchial   breathing   to   be   heard? 

Phthisis,    pneumonia,    some  cases   of   pleural   effusion, 
malignant  disease,  atelectasis. 

2.  Why   Is   the   pulmonic   second   sound   accentuated   here? 

Because  of  the  obstruction  to  the  pulmonary  circulation 
due  to  the  disease  below  described. 

3.  Is  the  eighth  interspace  a  safe  place  to  tap  in  a  case  like 


188  CASE   HISTORIES    IN   MEDICINE. 

this?  It  is  safe  if  the  diaphragm  is  not  pushed  up. 
In  hepatic  abscess  I  have  seen  the  liver  punctured 
(through  the  diaphragm)  by  a  needle  introduced  through 
the  eighth  space  in  the  posterior  axillary  line. 

Diagnosis :  Solidification  of  the  whole  lung,  lasting  eighteen 
days  and  proved  by  the  result  of  puncture,  might  be  due  to 
tuberculosis,  pneumonia  (unresolved),  or  malignant  disease. 
Loss  of  flesh  and  color  is  rare  in  unresolved  pneumonia. 
Prominence  of  one  chest  is  not  produced  by  tuberculosis, 
and  so  high  a  leucocytosis,  without  evidences  of  cavities 
and  purulent  sputa,  is  almost  unknown.  Malignant  disease 
was  found  at  autopsy  three  months  later. 

Prognosis:  There  is  no  hope  of  recovery  from  malignant 
disease  of  the  lung,  since  its  surgical  removal  is  impracti- 
cable and  metastasis  elsewhere  is  almost  certain  to  be  present. 
Life  is  not  likely  to  be  prolonged  beyond  a  few  months. 

Treatment:  If  serum  accumulates  in  the  pleura  upon  the 
affected  side,  some  relief  to  the  patient's  dyspnoea  may  be 
given  by  tapping  the  effusion  as  often  as  it  produces  distress. 
In  the  absence  of  better  remedies  it  is  perhaps  worth  while 
to  try  X-ray  exposures  which  may  have  some  influence  in 
delaying  the  further  progress  of  the  disease.  I  have  seen  no 
good  effects  from  Coley's  toxins  in  such  cases;  towards  the 
end  of  life  morphin  may  be  needed  to  relieve  suffering. 


DISEASES   OF   THE    RESPIRATORY   TRACT.  189 

Case  69.  A  married  lady  of  sixty- two  is  seen  March  i. 
The  family  and  previous  histories  are  good.  Three  years 
ago  the  left  breast  was  removed  by  a  competent  surgeon  for 
cancer.  Since  then  her  health  has  been  good  until  Decem- 
ber 15,  1902,  when,  for  failing  eyesight,  she  consulted  an 
oculist,  who  found  detachment  of  the  retina  in  the  left  eye. 

About  January  i ,  she  noticed  that  she  was  short  of  breath. 
After  this  she  kept  very  quiet  as  exertion  brought  on  dyspnoea. 
Dyspnoea  has  continued  her  main  complaint,  brought  on  by 
exertion,  but,  especially  of  late,  often  waking  her  from  sleep. 
About  two  weeks  ago  she  could  lie  on  the  right  better  than 
on  the  left  side;  since  then  there  has  been  orthopnoea.  She 
has  a  slight  dry  cough,  no  pain,  fever,  or  vomiting.  Bowels 
regular.  The  appetite  is  poor.  Loss  of  weight  has  not  been 
marked.  The  pulse  is  112,  regular.  The  right  chest  is  dull 
on  percussion  above,  fiat  below,  with  feeble  respiration, 
diminished  voice  sounds  and  fremitus.  There  is  puerile 
breathing  over  the  left  lung,  and  a  few  fine  rales  in  the  fifth 
interspace  in  front.  The  heart's  impulse  is  in  the  sixth  space, 
anterior  axillary  line.  The  sounds  are  clear.  The  abdomen 
is  negative;  the  urine,  1016-1018  In  specific  gravity,  contains 
neither  albumin  nor  sugar;  the  amount  Is  not  known,  but 
thought  to  be  normal  for  one  In  her  condition.  There  Is  no 
oedema. 

1.  Name  the  most  important  causes  of  dyspnoea.     Cardiac 

weakness,  emphysema,  pleural  effusion,  pneumonia. 

2.  (a)  Significance    of    orthopnoea?     (b)   In    what    diseases 

does  it  most  often  occur?  (a)  Orthopnoea  means 
dyspnoea  so  great  that  lying  down  causes  distress. 
(b)   It  Is  oftenest  seen  in  the  diseases  mentioned  above. 

3.  Causes  of  displacement  of  the  apex  Impulse?     Cardiac 

hypertrophy  or  dilatation,  pressure  of  pleural  effusion, 
pneumothorax,  or  of  subdiaphragmatic  tumors,  contrac- 
tion of  a  diseased  lung  with  pleural  and  pericardial  ad- 
hesions, situs  inversus,  thoracic  deformities. 

4.  At  what  age  is  pleural  effusion  most  common  ?    Under  forty. 

5.  Why  does  she  prefer  to  lie  upon  the  right  side  ?     Because 

that  frees  the  left  lung  for  breathing,  the  right  being 
embarrassed  by  hydrothorax. 

6.  What  symptoms  are  likely  to  develop  later  In  the  course 

of  this  case  ?  Pain,  oedema  of  the  right  arm  and  of 
the  adjacent  parts. 


190  CASE   HISTORIES   IN   MEDICINE. 

Diagnosis:  Evidence  of  pleural  effusion  coming  on  In  an 
elderly  woman  whose  breast  has  been  removed  for  cancer 
suggests  at  once  a  cancerous  metastasis  at  the  root  of  the 
lung.  A  simple  pleuritic  effusion  might  develop  at  this  age 
but  is  rare.  Hydrothorax  is  ruled  out  by  the  absence  of 
notable  cardiac  weakness.  Paracentesis  will  probably  decide 
the  diagnosis  by  revealing  a  heavy  bloody  fluid  such  as  is 
common  only  In  cancerous  effusions. 

Prognosis  and  Treatment:  (see  previous  case). 


DISEASES   OF   THE   RESPIRATORY   TRACT.  IQI 

Case  70.  A  heavy,  middle-aged  woman  "  took  cold  "  on 
Saturday  and  was  afterward  distressed  for  breath.  She  was 
seen  on  Tuesday  evening  sitting  up,  breathing  with  some 
difficulty  and  with  a  wheeze,  chiefly  with  expiration.  The 
face  was  red  but  not  livid.  She  complained  of  pain  at  the 
top  of  the  sternum  and  side  of  the  throat.  There  was  expec- 
toration of  white  frothy  mucus  and  some  tough  brown  masses. 
The  voice  was  suppressed.  The  tonsils  were  not  swollen, 
there  was  no  exudation  in  the  pharynx,  and  the  epiglottis  was 
not  swollen.  The  pulse  was  rapid.  The  physical  signs  were 
negative  with  the  exception  of  prolonged  expiration.  Tem- 
perature 99.9°. 

1.  {a)  What  are  the  commonest  causes  of  pain  referred  to 

the  sternum?  {b)  of  sore  throat?  {a)  Tracheitis,  asthma, 
weakened  or  embarrassed  heart,  aneurism,  mediastinal 
tumors,     {b)  Pharyngitis,  tonsillitis,  tonsillar  abscess. 

2.  In  what  diseases  do  patients  wheeze?     Asthma,  emphys- 

ema, some  cases  of  bronchitis,  bronchial  or  tracheal 
stenosis  from  cicatrix  (syphilis),  or  from  pressure  (aneu- 
rism or  tumor). 

3.  Significance  of  inspiratory  and  of  expiratory  dyspnoea? 

Inspiratory  dyspnoea  means  obstruction  in  the  upper  air 
passages  (*'  croup,"  diphtheria,  quinsy,  postpharyn- 
geal abscess,  foreign  bodies  in  the  larynx).  Expiratory 
dyspnoea  is  seen  chiefly  in  asthma  and  emphysema. 
Mixed  forms  occur  in  other  diseases  of  the  lungs  and  of 
the  heart. 

4.  How  might  blood  examination  help  in  the  diagnosis  of 

this  case?  The  absence  of  leucocytosis  would  help  to 
exclude  pneumonia. 

5.  What  should  you  expect  to  find  in  the  sputum?     Nothing 

of  any  diagnostic  significance. 

Diagnosis:  Laryngeal  diphtheria,  acute  laryngitis  with 
tracheitis  and  asthma,  Ludwig's  angina,  aneurism,  and  ''cen- 
tral "  pneumonia  are  the  most  important  possibilities.  The 
temperature  and  the  absence  of  any  physical  signs  on  the 
fourth  day  make  pneumonia  very  unlikely.  (This  opinion 
was  later  confirmed  by  the  finding  of  a  normal  leucocyte 
count  —  a  fact  which  helped  to  exclude  diphtheria  and  deep 
cervical  abscess.)  Ludwig's  angina  produces  tenderness  and 
swelling  (as  well  as  pain)  at  the  side  of  the  neck  and  throat. 


192  CASE   HISTORIES   IN   MEDICINE. 

Fever  and  leucocytosis  would  be  high.  Laryngeal  diphtheria 
was  excluded  by  laryngoscopic  examination,  which  also 
demonstrated  the  presence  of  acute  laryngitis  and  tracheitis. 
The  piping  rales  of  asthma  appeared  a  few  hours  later  (they 
are  often  very  fugitive) ,  and  this,  with  the  negative  results  of 
urinary  examination,  confirmed  the  diagnosis  of  bronchial 
asthma.  The  tough  brown  masses  appeared  to  come  from  the 
region  of  the  tracheal  bifurcation. 

Prognosis :  The  attack  is  not  a  severe  one  and  would  prob- 
ably have  passed  in  the  course  of  a  week  or  ten  days.  Such 
attacks  often  recur  but  are  never  serious. 

Treatment:  For  the  laryngitis  and  the  wheezing  nothing 
is  more  effective  than  the  inhalation  of  hot  steam,  with  or 
without  tincture  of  benzoin.  A  large  pitcher  of  hot  water  is 
held  up  to  the  patient's  face  and  a  towel  thrown  over  the 
head  so  as  to  confine  the  steam  somewhat.  In  this  way  a 
good  deal  of  the  vapor  may  be  inhaled  in  the  course  of  two 
or  three  minutes.  The  procedure  should  be  repeated  every 
few  hours  if  it  gives  relief. 

For  the  cough  nothing  is  better  than  heroin,  ^V  grain, 
given  every  five  or  six  hours.  The  patient  should  remain 
in  bed  as  long  as  there  is  any  fever,  and  may  be  fed  up  to  the 
limit  of  digestive  power.  There  is  no  good  reason  for  giving 
a  cathartic,  as  is  so  often  done,  unless  the  bowels  are  actually 
constipated. 


CHAPTER   VI. 
DISEASES    OF    THE    NERVOUS    SYSTEM. 

Case  71.  A  sewing-woman  of  fifty-nine  had  been  of  a 
nervous  temperament  all  her  life,  but  for  the  past  two  years 
this  has  been  much  worse  and  she  now  feels  "  all  disturbed." 
Her  sleep  is  heavy  but  she  often  wakes  up  frightened  and 
with  both  arms  asleep.  Though  she  passed  the  menopause 
ten  years  ago  she  is  frequently  troubled  by  a  "  rush  of  blood 
to  the  head  "  accompanied  by  hoarseness  and  a  sense  of  im- 
pending death.  These  attacks  are  much  commoner  in  win- 
ter. Every  summer  she  feels  much  better.  She  was  always 
stout  and  her  weight  has  decidedly  increased  in  the  past  ten 
years,  though  for  the  past  two  years  it  has  remained  unchanged. 
W^alking  easily  makes  her  wheeze  and  puff  and  she  notices 
that  her  clothes  are  much  tighter  at  night  than  in  the  morn- 
ing, especially  if  she  walks.  She  has  a  constant  sense  of  a 
weight  upon  her  head  and  a  hot  room  or  a  coal  fire  makes  her 
head  throb  painfully.  She  is  very  subject  to  forgetfulness 
and  to  spells  of  trembling.  Though  she  has  been  frequently 
urged  by  her  friends  to  bear  up  and  put  a  better  face  upon 
her  troubles  she  has  been  quite  unable  to  do  so  even  with  the 
aid  of  mental  treatment.  Nosebleeds  have  been  frequent 
during  the  past  winter. 

Diagnosis :  Prior  to  the  physical  examination  this  case  cer- 
tainly looks  very  much  like  a  psychoneurosis.  It  is  alwa3^s 
to  be  remembered,  however,  that  psychoneurosis  originating 
at  fifty-seven  in  a  person  who  has  never  previously  consulted 
a  doctor  is  exceedingly  rare,  and  that  many  of  the  symp- 
toms which  in  younger  people  have  no  serious  significance 
may  indicate  serious  cardiovascular  changes  occurring  in  a 
person  of  fifty-nine.  The  important  question  therefore  is: 
Can  we  detect  in  our  examination  any  sign  of  arteriosclerosis 
or  of  increased  vascular  tension  such  as  results  from  shrunken 

193 


194  CASE   HISTORIES    IN   MEDICINE. 

kidneys  ?  This  patient's  dyspncea  may  well  be  an  effect  of 
her  obesity.  In  a  younger  person  such  dyspnoea  is  often  a 
feature  of  pure  psychoneurosis  but,  as  above  hinted,  there 
are  more  serious  possibilities.  On  examining  this  patient  I 
found  to  my  chagrin  that  the  fat  layer  was  so  thick  as  abso- 
lutely to  prevent  any  estimation  of  the  cardiac  boundaries. 
The  heart  sounds  were  not  remarkable  and  the  arteries 
showed  no  sign  of  sclerosis. 

What  further  tests  remain  ?  Fortunately  we  have  one  test 
of  the  cardiovascular  apparatus  which  is  not  obscured  either 
by  the  thickness  of  the  fat  layer  or  by  the  inaccessibility  of 
the  internal  arteries  which  may  be  sclerotic  even  when  those 
at  the  periphery  are  normal.  I  refer  to  the  measurement  of 
blood  pressure.  When  we  find,  as  I  did  in  this  patient,  that 
the  systolic  pressure  is  constantly  above  i8o  mm.  Hg,  we 
may  dismiss  from  consideration  the  idea  that  the  patient's 
symptoms  are  due  to  a  pure  neurosis  or  to  a  simple  obesity. 
In  the  present  case  the  examination  of  the  urine  revealed  a 
nocturnal  excess,  a  low  specific  gravity,  and  an  increased 
amount.  Albumin  and  casts  were  absent.  My  diagnosis 
was :  Contracted  kidneys ;  hypertrophy  and  dilatation  of  the 
heart,  due  to  vascular  hypertension;  secondary  disturbances 
of  the  circulation  and  of  cerebral  function. 

Prognosis:  This  case  is  typical  of  innumerable  others 
which  have  come  more  prominently  to  our  notice  of  recent 
years  owing  to  the  use  of  instruments  for  measuring  blood 
pressure.  The  obesity  and  the  absence  of  albuminuria  often 
throw  us  off  the  track  of  the  cardiac  and  renal  disease,  but 
from  a  considerable  experience  in  the  post-mortem  examina- 
tion of  cases  presenting  a  similar  picture,  I  feel  that  we  can 
rely  upon  the  measurements  of  blood  pressure  to  guide  us 
aright  when  the  symptoms  are  similar  to  those  above  de- 
lineated. The  duration  of  life  in  cases  of  this  kind  depends 
upon  the  patient's  ability  and  willingness  to  curtail  his  ex- 
penditure of  vital  energy,  reduce  the  pace  of  living,  and  take 
things  easy  for  the  rest  of  his  life.  If  all  mental  and  physical 
strain  can  be  avoided  and  yet  boredom  and  ennui  escaped, 
such  patients  may  live  out  their  lives  in  very  tolerable  com- 
fort.    On  the  other  hand,  those  who  are  subject  to  unavoid- 


DISEASES    OF    THE   NERVOUS    SYSTEM.  195 

able  financial  or  domestic  worries  and  those  who  have  to  earn 
their  living  by  muscular  work  usually  succumb  within  a  year 
or  two  from  the  time  when  they  first  consult  the  physician. 

Treatment:  The  essentials  have  been  mentioned  in  the 
previous  paragraph.  Those  who  can  move  to  a  warm  climate 
in  which  the  skin  is  kept  active  can  probably  prolong  their 
lives  thereby.  I  have  not  found  that  the  use  of  nitroglycerin 
and  potassic  iodid  is  of  any  special  benefit,  though  it  is  cus- 
tomary to  give  these  drugs.  Moderate,  regular  outdoor  ex- 
ercise is  of  the  greatest  importance,  but  should  never  be 
pushed  to  the  point  of  getting  the  patient  out  of  breath.. 
Golf,  automobiling,  fishing,  yachting,  and  rich  men's  amuse- 
ments generally  are  of  undoubted  benefit. 


196  CASE  HISTORIES   IN  MEDICINE. 

Case  72.  A  middle-aged  man  was  seen  writhing  in  intense 
pain  referred  to  the  epigastrium.  Vomiting  of  greenish  fluid 
took  place;  there  were  loose  discharges  from  the  bowels,  small 
in  amount.  This  state  of  things  lasted,  with  only  short  re- 
missions, for  two  days,  until  a  small  dose  of  morphia  (which, 
for  special  reasons,  had  been  hitherto  withheld,  though  asked 
for)  was  administered,  after  w^hich  there  was  complete  relief 
for  many  days.  The  pupils  were  dilated,  the  pulse  regular 
and  of  normal  character.  Nothing  special  had  been  eaten 
or  drunk  to  cause  irritation  of  the  stom^ach.  The  abdominal 
walls  were  neither  distended  nor  retracted,  no  intra-abdominal 
tumor  was  detected,  nor  was  there  excessive  tenderness  on 
pressure.  It  was  afterwards  learned  that  he  had  had  several 
such  attacks,  that  for  many  months  or  years  his  legs  had  been 
weak,  that  he  had  had  neuralgia  and  numbness  in  them. 

1.  What  further  examinations  should  be  made?     Pupillary 

reactions,  knee-jerks,  temperature,  heart,  lungs,  blood, 
and  urine  are  the  most  important. 

2.  If  you  had  seen  such  a  case  for  the  first  time,  what  treat- 

ment of  the  acute  symptoms  should  you  advise  ?  Mor- 
phia subcutaneously. 

3.  Significance  of  the  vomiting  of  greenish  fluid?     Violent 

or  prolonged  vomiting  from  any  cause,  e.g.,  from  seasick- 
ness, squeezes  bile  into  the  duodenum  whence  it  regur- 
gitates into  the  stomach  and  is  vomited. 

Diagnosis:  The  epigastric  pain  is  probably  not  inflamma- 
tory in  origin  (peritonitis),  since  there  is  no  excessive  tender- 
ness or  rigidity,  and  a  small  dose  of  morphia  gives  relief  for 
many  days.  Lead  colic  is  not  often  associated  with  diarrhoea, 
while  the  pulse  usually  shows  increased  tension.  Evidences 
of  plumbism  and  the  possible  sources  of  lead  should  be 
searched  for.  Biliary  colic  cannot  be  excluded  without  fur- 
ther evidence.  A  history  of  jaundice  and  of  radiation  of  pain 
to  right  scapular  region  should  be  sought  for. 

The  weakness,  pain,  and  numbness  of  the  legs  suggest  either 
neuritis  (perhaps  due  to  lead)  or  tabes.  Examination  of  the 
pupils  showed  no  reaction  to  light,  although  the  reaction  to 
distance  was  normal.  The  knee-jerks  were  absent  and  Rom- 
berg's symptom  present.     The  acute  epigastric  pain  was  ex- 


DISEASES   OF   THE   NERVOUS    SYSTEM.  I97 

plicable  as  a  gastric  crisis  in  tabes  dorsalis.  Morphia  had 
been  withheld  because  the  patient  had  in  previous  years 
narrowly  escaped  the  habit.  No  evidence  of  lead  or  of  gall- 
stones could  be  obtained.  Other  causes  of  epigastric  pain  of 
less  severity  than  that  here  described  are  gastric  ulcer  and 
hyper chlorhydria .  (in  which  the  pain  has  more  obvious  rela- 
tion to  food  than  in  this  case),  malaria  (periodic  pain  with 
fever),  gastro-enteritis,  in  which  the  shifting  of  the  pain  and 
its  relation  to  food  and  to  bowel  movements  are  usually 
obvious. 

Prognosis:  We  can  truthfully  say  to  the  patient  with 
tabes  that  the  chances  are  that  he  will  never  be  paralyzed,  for 
statistics  show  that  in  the  majority  of  cases  death  occurs  from 
some  intercurrent  disease  before  the  spinal  lesion  has  reached 
the  point  of  absolute  paralysis.  This  is  a  crumb  of  encour- 
agement for  which  patients  are  usually  grateful. 

We  may  further  assure  the  patient  that  at  any  time  his 
disease  may  come  to  a  standstill  and  advance  no  more.  He 
is  not  bound  to  contemplate  a  future  of  steadily  aggravated 
suffering. 

There  is  a  certain  amount  of  evidence  to  show  that  benefits 
may  accrue  from  the  use  of  antisyphilitic  treatment  whenever 
the  spinal  fluid  shows  signs  of  a  low-grade  inflammation 
(lymphocytosis)  and  the  Wassermann  reaction  is  present. 
It  is  certainly  justifiable  to  give  such  medication  a  trial. 

The  symptoms  which  most  need  treatment  are  the  ataxia, 
the  lightning  pains,  and  the  gastric  crises.  For  the  ataxia 
much  can  be  done  in  intelligent  and  persevering  patients,  by 
the  use  of  Fraenkel's  reeducation  exercises,  the  details  of 
which  may  be  found  in  treatises  on  Neurology.  Really 
brilliant  results  may  be  obtained  now  and  then  in  this  way. 

For  the  lightning  pains  complete  rest  in  bed  with  massage 
and  appropriate  medication  sometimes  gives  relief,  though 
it  is  often  impotent.  The  best  remedies  at  our  command 
are  aspirin,  5  to  10  grains  every  four  hours,  and  pyramidon, 
the  average  dose  of  which  is  6  grains.  It  is  above  all  im- 
portant to  prevent,  by  every  means  in  our  power,  the  acquisi- 
tion of  that  morphia  habit  to  which  so  many  patients  are 
driven. 


198  CASE   HISTORIES   IN   MEDICINE. 

For  the  gastric  crises  rest  in  bed  with  starvation  is  all  that 
we  can  do,  unless  the  symptoms  are  so  severe  as  to  call  for 
the  operation  of  cutting  the  posterior  spinal  nerve  roots  in  the 
segment  corresponding  to  the  stomach  and  upper  intestines. 


DISEASES   OF   THE   NERVOUS    SYSTEM.  1 99 

Case  73.  A  manufacturer,  of  fifty-four,  of  good  inheritance 
and  habits,  is  seen  in  October,  1898.  In  childhood  he  was 
laid  up  for  a  time  with  what  he  thinks  was  rheumatism,  and 
he  has  since  had  pains  now  and  then,  not  laying  him  up, 
attributed  by  him  to  rheumatism.  He  has  been  a  very  active 
man  and  has  ridden  a  wheel.  Ten  years  ago  he  fell  on  the  ice 
while  skating,  striking  the  back  of  his  head.  He  was  uncon- 
scious for  a  week,  and  in  bed  eleven  weeks,  but  full  recovery 
followed.  For  the  past  year  he  has  been  less  well  and  strong. 
Last  winter  he  went  to  Bermuda,  gaining  in  every  way  and 
thirteen  pounds  in  weight.  Five  weeks  ago  he  drove  a  pair 
of  pulling  horses  over  forty  miles.  The  next  day  he  had  severe 
pain  in  his  arms,  and  this  has  since  been  his  main  complaint. 
The  pain  extends  from  the  shoulders  to  the  wrists,  is  worse  at 
night,  and  often  requires  morphia  to  secure  sleep.  Pain  and 
a  burning  sensation  in  the  fingers  come  on  suddenly  at  times, 
wax  and  wane.  He  has  kept  the  bed  for  about  four  weeks, 
sending  for  his  doctor  first  three  weeks  ago.  He  has  lost  some 
flesh.  The  bowels  are  constipated.  Of  late  there  has  been 
some  general  abdominal  colicky  pain  not  attributable  to  laxa- 
tives. Fever  has  been  absent.  There  is  no  cough  or  pre- 
cordial pain ;  he  lies  indifferently  on  either  side,  with  the  head 
low.  He  is  rather  pale,  with  slight  icteric  hue  of  the  con- 
junctivae. The  pulse  is  and  has  been  regular,  of  fair  strength, 
and  rather  low  tension,  96.  The  tongue  is  clear  and  moist, 
the  gums  and  teeth  in  good  condition. 

Tactile  sensibility  is  perfect.  There  is  weakness  in  the 
arms  and  hands,  especially  in  the  extensor  muscles.  This 
weakness  has  increased  notably  in  the  past  week.  He  can 
button  his  undershirt  and  pick  up  a  pin  from  a  smooth  sur- 
face, though  with  difficulty.  There  is  no  distortion  of  the 
finger  joints. 

The  cardiac  impulse  is  in  the  fifth  space  one  inch  to  the  left 
of  the  mammary  line.  Percussion  corresponds  with  palpa- 
tion and  shows  slight  extension  of  dulness  on  the  right  of  the 
sternum.  In  both  the  mitral  and  aortic  areas  soft  systolic 
murmurs  are  to  be  heard,  one  transmitted  into  the  axilla,  the 
other  into  the  neck.  The  second  sounds  are  clear,  the  pul- 
monic sound  slightly  accentuated.     Visceral  examination  is 


200  CASE   HISTORIES   IN   MEDICINE. 

Otherwise  negative.  (Edema  is  absent.  The  knee-jerks  are 
obtained,  though  with  difficulty.  The  urine,  44  ounces  in 
twenty-four  hours,  contains  neither  sugar  nor  albumin. 
The  blood  is  normal. 

1.  What  diseases  are  most  often  diagnosed  as  "  rheumatism"  ? 

Osteomyelitis,  neuritis,  arthritis  deformans,  tabes,  gall- 
stones, trichiniasis,  tuberculous  or  syphilitic  osteitis, 
aortic  aneurism. 

2.  What  connection  can  be  traced  between  the  fall  and  coma 

of  ten  years  ago  and  the  present  symptoms  ?  In  all 
probability  there  is  no  connection  at  all. 

3.  {a)   Common  causes  of  muscular  weakness  ?     {b)  of  mus- 

cular paralysis?  {a)  Malnutrition  (due  to  poverty, 
stomach  or  bowel  trouble),  diabetes,  nephritis,  anaemia, 
fevers,  or  cancer;  psychic  disturbances  (muscular  col- 
lapse from  fright  or  sorrow;  neurasthenia,  hysteria). 
The  beginning  of  the  lesions  mentioned  next,  {b)  Neu- 
ritis (traumatic,  toxic,  infectious),  apoplexy  (usually 
producing  hemiplegia),  anterior  poliomyelitis,  birth 
palsies,  dementia  paralytica,  myelitis  (from  pressure  or 
unknown  cause),  hysteria. 

4.  {a)  What  information  might  be  obtained  by  testing  the 

power  of  the  supinator  longus  here  ?  {b)  Describe  the 
test,  (a)  Lead  neuritis  spares  the  supinator  longus, 
while  in  traumatic  neuritis  of  the  arm  the  supinator  is 
usually  paralyzed,  {b)  Stand  before  the  patient,  who 
bends  his  arm  at  the  elbow  to  a  right  angle.  Grasp  his 
hand  and  resist  while  he  tries  to  draw  his  hand  towards 
his  shoulder.  If  the  supinator  is  sound  it  will  stand  out 
obviously  on  the  thumb-side  of  the  arm. 

5.  What    relations    are    there    between   joint    troubles    and 

diseases  or  anomalies  of  the  nervous  system  ?  In  tabes 
and  syringomyelia  painless  but  very  destructive  joint 
troubles  may  occur  ("  Charcot's  Joint  ").  In  many 
chronic  joint  troubles  muscular  atrophy  is  exceedingly 
rapid  and  the  reflexes  are  increased. 

6.  What  connection  might  exist  between  the  cardiac  and  the 

peripheral  symptoms  ?  Local  anaemia  or  toxaemia  might 
be  the  cause  of  both. 

Diagnosis:  Pain,  muscular  weakness  (extensors),  dimin- 
ished knee-jerks,  and  colic  with  no  anaesthesia  or  paraesthesia 
suggest  neuritis  —  especially  that  due  to  lead.  There  are  no 
signs  suggesting  involvement  of  the  brain,  cord,  or  muscles 


DISEASES   OF   THE   NERVOUS    SYSTEM,  201 

(myositis).  The  cardiac  signs  are  those  of  a  dilated  heart, 
probably  due  to  weakness  of  its  muscle.  An  examination  of 
the  urine  showed  a  large  amount  of  lead,  apparently  derived 
from  drinking  water.  The  blood  showed  moderate  second- 
ary anaemia  with  an  unusually  large  number  of  normoblasts 
and  marked  stippling. 

Prognosis:  In  these  days,  when  the  diagnosis  is  usually 
made  early  in  the  course  of  the  disease,  the  saturnine  enceph- 
alopathy, which  is  sometimes  fatal,  is  very  rarely  met  with 
and  the  more  extensive  and  incapacitating  forms  of  paralysis 
are  much  less  frequent.  To  a  patient  with  extensive  paraly- 
sis one  may  say  truthfully  that  he  will  probably  regain  the 
most  part  if  not  the  whole  of  his  power.  Permanent  residual 
paralyses,  however,  affecting  certain  groups  of  muscles, 
result  In  the  severest  cases.  If  a  definite  nephritis  has  been 
produced  by  the  lead,  it  is  in  all  probability  incurable,  and 
the  same  is  obviously  true  of  the  arteriosclerosis  in  the  pro- 
duction of  which  lead  may  be  a  factor. 

The  colics,  gum  deposits,  and  blood  changes  which  char- 
acterize the  milder  types  of  plumbism  ought  wholly  to  dis- 
appear under  proper  treatment. 

Treatment:  To  find  and  remove  the  source  of  the  toxic 
lead  is  often  easier  said  than  done.  The  habits  of  many 
painters  are  fixed  beyond  reformation.  If  the  lead  is  taken 
in  through  the  alimentary  tract  in  drinking  water  or  beer  it 
should  be  comparatively  easy  to  exclude  it. 

As  soon  as  the  source  of  lead  is  excluded,  most  patients 
begin  to  improve  rapidly.  Probably  this  improvement  may 
be  accelerated  by  giving  half  an  ounce  of  magnesium  sulphate 
every  morning  and  also,  as  I  believe,  by  small  doses  of  iodid  of 
potash.  How  this  drug  acts  is  not  at  all  clear,  but  I  am  not 
yet  convinced  that  it  is  useless  in  lead  poisoning. 

For  the  paralysis  our  chief  resource  is  to  urge  and  encourage 
the  patient  to  use  all  the  power  that  he  has.  Electricity  and 
massage  sometimes  help  towards  this  end. 


202  CASE   HISTORIES   IN   MEDICINE. 

Case  74.  A  mechanic  forty- two  years  old  is  seen  June  15. 
His  family  history  is  unimportant.  He  had  pneumonia  in 
boyhood  and  grip  six  years  ago.  He  has  had  repeated  at- 
tacks of  gonorrhoea  but  denies  syphilis.  Four  years  ago  he 
had  sharp  neuralgic  pains  in  the  calves  of  his  legs  which  lasted 
a  month,  but  his  general  health  was  good  up  to  June,  two 
years  ago,  when  he  had  an  attack  of  severe  epigastric  pain 
with  vomiting  after  a  supper  of  corned  shoulder.  These 
attacks  have  been  frequently  repeated  and  the  intervals, 
which  were  at  first  two  weeks  or  more,  have  been  shortened 
until  during  the  past  month  his  physician  has  been  sum- 
moned thirteen  times.  One-half  to  one-third  of  a  grain  of 
morphia  subcutaneously  is  required  to  subdue  the  pain. 
Food  has  no  apparent  influence.  The  attacks  usually  come 
on  before  breakfast  and  consist  of  severe  epigastric  pain, 
nausea,  and  vomiting.  There  is  never  any  food  in  the  vomi- 
tus  of  the  morning  attack,  and  between  attacks  there  are  no 
digestive  symptoms  except  constipation.  His  weight  has 
fallen  from  180  to  165  pounds. 

Physical  examination  shows  a  rather  pale  man  looking 
older  than  his  years.  The  temporal  arteries  are  tortuous 
and  the  radials  are  somewhat  thickened.  The  pupils  are 
unequal,  the  left  being  the  larger.  Sensation  is  everywhere 
normal.  Knee-jerks  are  absent.  The  lower  limit  of  the 
stomach,  when  gently  inflated,  extends  to  the  umbilicus. 
Its  upper  limit  is  normally  situated.  No  tumor  is  felt  after 
or  before  inflation.  The  examination  of  the  stomach  con- 
tents made  between  the  attacks  and  after  the  usual  test  meal 
of  bread  and  water  show  free  HCl  present  .05%,  total  acidity 
.22%.  No  mucus.  Capacity  50  ounces.  Urine  1020,  acid, 
normal  color,  no  sugar,  no  albumin.  Temperature,  pulse,  and 
respiration  normal.  Careful  physical  examination  shows  no 
other  signs  of  importance. 

Diagnosis:  So-called  neuralgic  pains  in  the  legs,  attacks  of 
epigastric  pain,  uninfluenced  by  food  and  requiring  morphia 
for  their  relief,  are  very  significant  symptoms  when  taken  in 
connection  with  the  absence  of  knee-jerks  and  the  negative 
results  of  gastric  examination.  Tabes  dorsalis  with  pains 
and  gastric  crises  is  at  once  suggested.     It  will  be  noted  that 


DISEASES   OF   THE   NERVOUS    SYSTEM.  203 

the  record  shows  nothing  about  the  reaction  of  the  pupils. 
As  a  matter  of  fact  they  did  not  respond  to  Hght  but  reacted 
normally  to  distance,  thus  confirming  the  diagnosis.  A  great 
many  cases  of  this  type  are  mistaken  for  gastric  or  intestinal 
disease.  I  have  made  this  mistake  twice  myself,  yet  such 
mistakes  would  almost  always  be  avoided  if  we  were  invari- 
ably conscientious  in  our  examinations  of  pupils,  knee-jerks, 
and  ankle-jerks.  Within  a  year  I  have  known  patients  oper- 
ated upon  for  appendicitis,  for  pancreatitis,  and  for  cancer  of 
the  intestine,  when  the  diagnosis  proved  to  be  tabes. 

Prognosis:  We  can  truthfully  assure  the  patient  that  the 
great  majority  of  cases  of  tabes  never  become  paralyzed. 
This  is  important,  because  one  of  the  patient's  chief  fears  is 
certain  to  lead  in  this  direction.  The  majority  of  cases  be- 
comes arrested  or  dies  of  some  other  afifection  before  the  stage 
of  paralysis  is  reached.  Gastric  crises  are  very  intractable. 
Indeed  I  have  never  seen  any  treatment  that  seemed  to  me 
to  have  any  marked  influence  upon  them,  but  in  a  good 
many  cases  they  spontaneously  cease,  or  become  so  much 
milder  that  the  patient  is  able  to  tolerate  them  with  equa- 
nimity. The  same  may  be  said  of  the  pains  which  bothered 
him  very  much  four  years  ago  but  are  now  not  troublesome. 

Treatment:  It  is  rational  to  give  antisyphilitic  treatment  in 
all  cases  of  tabes,  provided  the  Wassermann  reaction  is  posi- 
tive, or  whenever  there  is  evidence  in  the  fluid  obtained  by 
spinal  puncture  that  a  low-grade  inflammatory  process  is  still 
going  on.  Aside  from  the  administration  of  mercury  and  po- 
tassic  iodid,  our  treatment  should  be  hygienic.  Otherwise  there 
is  nothing  to  be  done  unless  ataxia  manifests  itself.  In  that 
case  much  can  be  accomplished  for  the  relief  of  this  symptom 
through  the  reeducation  exercises  generally  associated  with 
the  name  of  Fraenkel. 


204  ,        CASE   HISTORIES   IN   MEDICINE. 

Case  75.  The  patient  is  a  contractor  of  fifty.  He  is  of 
heavy  build,  stout  and  red  in  the  face.  For  several  years  he 
has  had  violent  cough  in  the  winter,  accompanied  by  vomit- 
ing. A  daughter  of  sixteen  some  years  ago  ran  off  with  a 
man  and  got  married.  He  took  to  his  bed,  cursed,  cried, 
called  for  his  pistols,  and  was  going  to  kill  the  husband,  but 
calmed  down  soon  and  the  young  people  were  sent  for.  His 
physician  thinks  he  does  not  use  alcohol  in  notable  excess. 
Two  weeks  ago  he  began  to  complain  of  tearing  and  cutting 
pains  in  his  legs,  accompanied  by  slight  oedema,  and  for 
several  days  now  he  has  been  in  his  bed.  Fever  has  been 
absent.  There  has  been  some  vomiting,  not  specially  charac- 
teristic in  any  way.  He  has  been  much  excited  and  has  threat- 
ened to  kill  all  Democrats.  Sleep  has  been  poor.  The  pains  in 
the  legs  have  continued,  but  less  severely  since  he  took  to  bed. 

The  pulse  is  80,  regular,  the  tongue  heavily  coated,  thorax 
negative.  The  edge  of  the  liver  can  be  felt  two  inches  below 
the  costal  border,  apparently  smooth  of  surface.  Motion 
and  tactile  sensibility  in  the  legs  seem  normal,  but  the  leg 
muscles  are  tender  and  the  knee-jerks  are  very  slight,  even 
on  reenforcement.     The  urine  report  is  negative. 

1.  What  important  facts  about  his  early  history  do  we  need 

to  know?  Has  he  had  syphilis?  How  much  alcohol 
has  he  taken? 

2.  Why  is  his  sleep  poor  ?     Poor  sleep  in  an  active  man  should 

always  suggest  alcoholism,  though  there  are  of  course 
many  other  causes. 

3.  Why  is  the  liver  smooth?     All  types  of  enlarged  liver 

(except  those  due  to  cancer  and  syphilis)  are  usually 
smooth  as  felt  through  the  belly  wall.  The  "  hobnails  " 
of  cirrhosis  can  rarely  be  felt,  so  that  smoothness  does 
not  exclude  cirrhosis.  Fatty  infiltration  seems,  how- 
ever, more  probable. 

4.  What  is  meant  by  reenforcement  of  knee-jerks?     We  dis- 

tract the  patient's  attention  and  concentrate  brain  con- 
trol on  the  muscles  of  his  hands  by  making  him  lock 
his  hands  together  and  then  break  them  apart  just  when 
we  tap  on  the  patella  tendon.  This  tends  to  "  bring 
out  "  knee-jerks. 

5.  How  is  the  oedema  of  the  legs  to  be  accounted  for  ?     (See 

diagnosis.) 


DISEASES   OF   THE   NERVOUS    SYSTEM.  205 

Diagnosis:  The  pains  and  tenderness  in  the  legs,  with 
diminished  knee-jerks  and  oedema,  strongly  suggest  neuritis. 
The  pupils  must  be  tested.  If  they  are  normal,  tabes  is  un- 
likely, especially  as  the  pains  here  present  are  not  at  all 
characteristic  of  tabes.  It  should  be  pointed  out  that  cedema 
is  not  uncommon  in  neuritis,  not  only  in  the  epidemic  form 
("wet"  beriberi)  but  in  ordinary  alcoholic  cases.  Other 
causes  of  cedema  (cardiac,  renal,  hemic,  local  —  e.g.,  varicose 
veins)  must  be  excluded. 

The  cause  of  the  neuritis  is  probably  alcoholism,  despite 
his  physician's  statement.  This  would  also  explain  mental 
symptoms,  vomiting,  and  enlarged  liver.  Dementia  paral- 
ytica is  possible  but  not  probable  in  view  of  the  local  signs 
in  the  legs  and  liver.  ■* 

Prognosis:   The  outlook  depends  upon: 

(i)  The  type  of  the  disease. 

(2)  Its  duration. 

(3)  The  inheritance  and  character  of  the  patient. 

(4)  The  spiritual  and  physical  environment. 

(5)  The  presence  or  absence  of  complicating  diseases. 
True  dipsomania,  in  which  a  paroxysm  of  drinking  occurs 

from  time  to  time,  as  it  were  out  of  a  clear  sky,  without  any 
previous  desire  or  craving  on  the  patient's  part,  is  almost  if 
not  quite  incurable.  Some  observers  believe  it  to  be  a  phys- 
ical equivalent  of  epilepsy. 

Excluding  true  dipsomania  we  have  left  the  acute  and  the 
chronic  types  of  ordinary  alcoholism.  That  the  latter  is 
proportionately  more  difficult  to  check  is  obvious  enough. 
Other  things  being  equal,  the  younger  the  patient  the  better 
the  outlook. 

When  the  patient  is  a  degenerate  or  when  his  family  history 
is  deeply  marked  with  epilepsy,  tuberculosis,  insanity,  or 
criminality  the  prognosis  is  much  worse  than  in  the  ordinary 
types  of  alcoholism  without  any  special  hereditary  taint. 
Besides  the  type  of  person  just  alluded  to  one  sees  many  cases 
of  alcoholism  which  are  practically  hopeless  because  the 
patient  has  no  genuine  desire  to  get  well. 

Excluding  now  the  dipsomaniacs,  the  degenerates,  and  the 
well-satisfied  drinkers  we  still  have  left  a  great  majority  of 


206  CASE   HISTORIES   IN   MEDICINE. 

all  cases  which  are  curable  if  sufficient  time,  energy,  and  money 
are  devoted  to  them.  It  is  essentially  a  moral  and  edu- 
cational problem  involving  friendly  supervision  over  a  long 
period  of  years.  Drugs  have  little  to  do  with  it  except  in 
the  acute  stages.  Our  task  is  substantially  that  of  making 
the  patient  believe  that  recovery  is  possible,  and  of  helping 
him  to  develop  a  motive  and  interest,  personal  or  impersonal, 
which  is  strong  enough  to  abolish  the  tendency  to  drink. 
There  must  be  someone  to  whom  the  patient  is  both  able  and 
willing  to  come  at  any  time  of  the  day  or  night  when  he  feels 
the  craving  for  drink.  The  company  and  influence  of  a  friend 
may  be  sufficient  to  enable  him  to  tide  over  the  hours  until 
the  craving  passes  by.  It  is  also  important  to  warn  the 
patient  against  the  dangers  of  fatigue  which  is  very  prone  to 
transform  itself  into  depression  and  a  desire  for  the  oblivion 
given  by  drink. 

When  attempting  to  break  a  patient  of  a  firmly  established 
habit,  it  is  often  well  to  begin  with  a  couple  of  weeks  in  some 
sanatorium  where  the  Towns-Lambert  plan  of  treatment  or 
some  equivalent  may  be  carried  out. 

The  complications  of  alcoholism,  such  as  the  neuritis 
present  in  the  case  now  under  discussion,  usually  need  no 
treatment.     They  get  well  when  the  alcoholism  is  overcome. 


DISEASES   OF   THE   NERVOUS    SYSTEM.  207 

Case  76.  A  shoemaker  of  twenty-four,  who  has  previously 
been  well,  has  noted  for  six  months  a  gradually  increasing 
weakness  of  the  legs.  He  dates  the  trouble  from  a  fall  from  a 
horse  car  six  months  before,  when  he  struck  violently  upon  his 
knees  and  fell  several  times  more  on  his  way  home.  He  kept 
at  work  till  three  months  ago,  when  he  took  a  three  weeks' 
vacation  and  improved  considerably,  but,  on  returning,  found 
himself  unable  to  work  more  than  half  a  day. 

Two  months  ago  the  hands  and  arms  began  to  get  weak  and 
numb,  and  now  he  can't  button  his  collar.  The  hands  feel 
rather  better  when  he  stirs  about  and  uses  them.  For  the 
past  week  he  has  felt  as  if  something  was  tied  tightly  about 
his  waist.  In  other  respects  he  feels  perfectly  well.  He  has 
never  used  alcohol  and  denies  venereal  disease. 

Examination:  Pupils  equal  and  react  normally.  Soft  sys- 
tolic murmur  at  the  apex,  transmitted  two  inches  to  the  left. 
Pulmonic  second  decidedly  louder  than  aortic.  No  evidences 
of  cardiac  enlargement.  Chest  and  belly  otherwise  negative. 
Deep  tenderness  over  calves,  thighs,  and  buttocks.  Knee- 
jerks  absent,  muscular  power  feeble,  sensation  perfect,  mod- 
erate general  atrophy.  Faradic  irritability  of  the  muscles 
impaired  In  both  arms  and  legs.  Galvanic  irritability  normal. 
At  times  the  tips  of  the  fingers  sweat  profusely. 

When  seen  his  temperature  was  99.8°,  pulse  120,  respira- 
tion 24. 

1 .  What  can  be  inferred  from  the  mode  of  onset  here  ?     The 

fall  was  not  the  cause  but  only  the  first  manifestation 
of  his  trouble. 

2.  What  can  be  inferred  from   the  atrophy?     It  indicates 

neuritis,  not  tabes. 

3.  Causes  and  types  of  atrophy?     Disuse,  neuritis,  progres- 

sive muscular  atrophy,  chronic  joint  disease,  poliomyel- 
itis anterior,  amyotrophic  lateral  sclerosis. 

4.  Causes  of  muscular  tenderness?     Neuritis,  myositis  (e.g., 

trichiniasis),  oedema  or  inflammation  of  neighboring 
tissues. 

5.  What  other  types  of  tenderness  are  there?     Cutaneous 

hyperaesthesia,  serous  membrane  hyperaesthesia  (as  in 
appendicitis  and  other  abdominal  lesions),  bone  tender- 
ness, as  in  periostitis,  nerve  tenderness,  as  in  neuritis. 

6.  What  do  (a)  the  electrical  reactions  In  this  case  teach  ? 

(b)  the  sweating  fingers  ?  (a)  Typical  reaction  of  degen- 
eration is  absent,     (b)  Vasomotor  changes. 


208  CASE   HISTORIES   IN   MEDICINE. 

Diagnosis:  Muscular  weakness  and  tenderness  with  absent 
knee-jerks,  atrophy,  and  partial  reaction  of  degeneration 
all  suggest  neuritis.  In  tabes,  there  is  no  tenderness  and 
muscular  power  is  good.  In  progressive  muscular  atrophy 
the  knee-jerk  is  not  lost  so  early  and  sensory  symptoms  are 
usually  absent.  The  slight  fever  points  towards  neuritis, 
likewise  the  vasomotor  symptoms.  The  cause  of  the  neuritis 
cannot  be  guessed  from  the  data  before  us. 

Prognosis:  Cases  of  multiple  neuritis,  such  as  that  here 
described,  without  any  known  cause,  almost  always  get  well 
after  a  tedious  convalescence  which  is  apt  to  last  months. 
Relapses  are  rare.  Presumably  they  are  due  to  some  infec- 
tious disease  which  does  not  recur. 

Treatment:  The  relief  of  pain  is  our  first  and  most  difficult 
task.  The  effects  of  heat  and  cold  must  first  be  tried.  Some 
patients  can  be  kept  comfortable  by  the  constant  applica- 
tion of  ice-bags  or  of  menthol.  More  frequently  relief  is 
obtained  by  poulticing  or  by  the  application  of  an  electric 
pad  which  keeps  its  heat  better  than  any  poultice.  I  have 
never  seen  any  considerable  benefit  from  blisters  or  mustard. 

If  these  measures  are  useless,  or  need  to  be  supplemented, 
the  application  of  high  frequency  electricity  may  give  relief. 
Massage  is  rarely  of  value  in  the  earliest  and  most  painful 
stages  of  the  disease.  Sometimes  it  is  necessary  to  resort  to 
the  use  of  morphia,  but  this  should  never  be  tried  unless  we 
believe  that  the  patient  is  wearing  out  his  strength  as  a  result 
of  unrelieved  suffering  and  that  the  harm  done  by  the  morphia 
will  be  the  less  of  two  evils.  Before  using  morphia  we  should 
always  avail  ourselves  to  the  fullest  extent  not  merely  of 
counterirritation  and  electricity  but  of  the  other  drugs  which 
dull  pain.  Aspirin  may  first  be  tried  in  doses  of  5  to  lo 
grains,  every  four  hours.  Phenacetin  10  grains,  pyramidon  6 
grains,  or  acetanilid,  2  to  5  grains,  should  next  be  tried.  I 
have  never  seen  any  relief  from  cannabis  indica  or  gelsemium. 

After  the  pain  has  passed  there  is  generally  a  long  period 
when  our  chief  task  is  to  restore  tone  and  power  to  the 
atrophic  muscles.  Massage,  passive  motion,  and,  above  all, 
the  individual's  own  effort,  generally  bring  about  full  recovery 
in  the  long  run. 


DISEASES   OF   THE   NERVOUS    SYSTEM.  209 

Case  77.  A  young  married  woman  of  twenty-one  had  an 
abortion  done  at  the  third  month.  Immediately  following 
this  she  began  to  vomit  occasionally,  and  after  two  days 
could  retain  nothing.  The  lochia  were  sweet,  temperature 
normal,  and  there  was  no  tenderness  in  the  pelvis.  Rectal 
alimentation  was  tried  for  three  days  and  the  vomiting  ceased, 
but  recommenced  as  soon  as  liquids  were  given  by  mouth. 
Again  rectal  feeding  was  tried,  but  this  time  the  vomiting 
did  not  cease.  The  nutrient  enemata  are  fairly  well  borne, 
the  nurse  says,  but  the  patient  is  very  sleepless  and  thirsty 
and  has  four  or  five  severe  retching  spells  in  every  twenty- 
four  hours.  She  is  seen  in  consultation  on  the  sixth  day  of 
rectal  feeding. 

The  temperature  and  pulse  are  normal  as  they  have  been 
throughout;  the  voice  clear  and  the  patient  moves  strongly 
in  bed.  Examination  of  the  chest,  belly,  and  pelvis  is  entirely 
negative. 

1.  How  can  we  determine  during  rectal  feeding  whether  the 

enemata  are  being  well  borne  and  absorbed  ?  In  ideal 
cases,  there  is  no  thirst  or  insomnia,  hunger  is  appeased 
by  the  enema,  nothing  comes  aw^ay  except  with  the 
daily  cleansing  enema,  and  little  weight  is  lost. 

2.  What    means   should  be  used  to  control  the  retching  in 

this  case  ?     (See  below  —  Treatment.) 

3.  What  important  parts  of  physical  examination  have  been 

omitted  ?     Urinalysis  and  blood  examination. 

4.  Significance  of  the  normal  pulse  and  temperature  here? 

Prostration  is  not  great;  infection  probably  absent. 

Diagnosis :  Pelvic  sepsis  is  excluded  by  the  normal  lochia, 
the  absence  of  fever,  pain,  and  pelvic  tenderness.  Retrover- 
sion of  the  uterus  is  said  to  produce  vomiting  in  some  cases 
of  this  type,  but  the  pelvic  examination  excludes  this.  Can 
the  vomiting  be  ursemic  ?  To  determine  this,  we  examined 
the  urine  and  found  it  normal.  (The  blood  was  also  normal.) 
The  rectal  feeding  was  evidently  a  failure  despite  the  nurse's 
assurance,  and  the  patient's  nervous  system  was  kept  irritable 
by  semistarvation.  Could  this  account  for  the  vomiting? 
In  view  of  the  negative  results  of  physical  examination  it 
seems  the  most  probable  diagnosis.     Had  the  enemata  been 


210  CASE   HISTORIES   IN   MEDICINE. 

well  absorbed  the  nervous  system  would  probably  have  been 
sufficiently  nourished  to  control  the  vomiting  center.  As  it 
is,  she  is  getting  no  food  and  losing  much  sleep.  Naturally 
the  vomiting  continues. 

Prognosis:  I  shall  consider  here  not  the  prognosis  of  the 
ordinary  toxaemic  vomiting  of  pregnancy,  but  of  the  neurotic 
type  such  as  was  exemplified  in  this  case.  Recovery  depends 
upon  our  power  to  win  the  patient's  nearly  exhausted  confi- 
dence and  to  switch  off  both  her  mind  and  her  stomach  onto 
a  new  track.  The  advent  of  a  new  personality  and  a  new 
method  of  treatment  is  helpful  chiefly  by  the  novelty  and 
only  to  a  minor  extent  by  actual  merit. 

Treatment:  Since  the  patient  vomits  despite  all  that  can 
be  done  and  despite  the  entire  absence  of  food  in  the  stomach, 
she  may  as  well  be  given  a  chance  to  vomit  in  a  better  cause 
—  i.e.,  she  may  as  well  be  fed.  Probably  not  all  that  is 
given  will  be  expelled  and  the  little  that  is  retained  will 
serve  to  nourish  her  and  so  to  check  the  vicious  activity  of 
the  vomiting  center.  When  we  arrive  at  this  conclusion  and 
are  prepared  to  resume  feeding,  it  is  very  important  to  secure 
if  we  can,  as  an  entering  wedge,  some  food  (no  matter  how 
outlandish  or  indigestible)  for  which  the  patient  has  a  posi- 
tive desire.  Such  a  food  is  far  more  likely  to  be  retained 
and  so  to  break  up  the  vicious  circle  by  which  the  vomiting 
has  led  to  malnutrition  and  malnutrition  to  vomiting.  I 
have  seen  the  spell  broken  by  gratifying  the  patient's  desire 
for  celery,  for  cold  sausage,  for  corn-meal  mush,  and  for 
brandy  with  shaved  ice.  Each  of  these  foods  has  been,  in 
an  individual  case,  the  entering  wedge  or  starting  point  for 
successful  resumption  of  stomach  feeding.  It  is  far  more  im- 
portant to  get  something  that  the  patient  really  relishes  than 
to  administer  a  bland  and  chemically  innocuous  substance 
such  as  milk  or  gruel.  Many  a  patient  has  begun  to  improve 
as  soon  as  she  has  been  taken  off  a  diet  of  "  slops  "  and  given 
solid  food  with  a  strong  taste  to  it. 

Curiously  enough,  it  is  a  fact  that  some  people  can  be 
made  to  stop  vomiting  by  being  scolded  or  otherwise  abused. 
A  physician  of  my  acquaintance  administers  in  such  cases  a 
subpectoral  infusion  of  saline  solution  and  tells  the  patient 


DISEASES   OF   THE   NERVOUS    SYSTEM.  211 

that  unless  she  stops  vomiting  this  painful  process  will  have 
to  be  repeated  every  day.  Strange  though  it  appears  this 
treatment  works  well  in  properly  selected  cases  and,  like 
other  forms  of  corporal  punishment,  is  doubtless  justifiable. 


212  CASE   HISTORIES   IN   MEDICINE. 

Case  78.  A  contractor  of  fifty-three  consulted  me  June 
27,  1910,  complaining  of  a  gradual  loss  of  weight  (24  pounds 
in  fifteen  years),  with  a  distressing  palpitation  at  the  epigas- 
trium accompanied  by  a  sense  of  weakness  there,  especially 
if  he  takes  any  stimulant. 

He  is  also  troubled  by  a  varicocele  —  the  result,  he  says, 
of  dissipation  in  his  youth  which  involved  an  infection  with 
gonorrhoea,  but  no  syphilis. 

For  five  years  he  has  been  very  sensitive  to  cold  and  has 
therefore  felt  much  better  in  summer,  but  this  summer  people 
tell  him  that  he  looks  sick  and  his  head  is  often  tired.  His 
sleep  is  restless  during  the  past  six  months,  and  he  is  often 
drowsy  in  the  daytime.  His  hand  is  often  unsteady,  especially 
in  the  mornings,  and  he  has  three  times  dropped  a  glass. 

His  use  of  alcohol  is  very  moderate,  as  he  has  noticed 
that  it  increases  the  abdominal  pulsation  above  mentioned. 
Within  the  last  tvvo  months  his  appetite  has  been  poor,  per- 
haps because  he  has  had  all  his  teeth  removed  and  is  not 
yet  used  to  his  plates. 

He  has  had  much  treatment  addressed  to  the  stomach  and 
bowels  (which  are  always  costive),  but  has  seen  no  improve- 
ment. 

1 .  Relation  of  varicocele  to  sexual  excesses  ?     There  is  none, 

though  quacks  endeavor  to  persuade  their  dupes  that 
masturbation  or  venereal  disease  is  the  cause.  Vari- 
cocele is  rarely  if  ever  a  disease.  It  is  a  common 
idiosyncracy  —  occasionally  needing  support  by  a  sus- 
pensory, very  rarely  requiring  excision. 

2.  Causes  of  epigastric  pulsation  ?     Negative  pressure  owing 

to  the  contraction  of  a  low-placed  heart,  cardiac  or 
aortic  pulsation  transmitted  through  the  liver,  or  in 
rare  cases  through  an  epigastric  tumor,  dynamic  aorta, 
aneurism  of  the  abdominal  aorta,  local  dilatation  of  the 
right  ventricle  in  mitral  stenosis. 

Diagnosis:  Physical  examination  revealed  nothing  wTong 
in  the  chest,  urine,  or  blood.  In  the  epigastrium  there  was 
a  very  marked  and  lively  pulsation  but  no  tumor. 

A  cylindrical  mass  about  the  size  of  the  aorta  was  felt 
immediately  beneath  the  abdominal  wall.     A  thrill  and  sys- 


DISEASES   OF   THE   NERVOUS    SYSTEM.  213 

tolic  murmur  were  elicted  by  pressure  over  it.  Its  pulsation 
was  distinctly  expansile,  i.e.,  lateral  as  well  as  vertical. 

The  patient  was  rather  thin  (weight  136)  but  showed  no 
other  lesions.     Blood  pressure  1 10. 

Aneurism  or  dynamic  (i.e.,  lively)  aorta  are  the  only  prob- 
able diagnoses.  Aneurism  is  excluded  by  the  absence  of 
dorsal  and  sciatic  pain,  the  absence  of  definite,  usually  un- 
symmetrical,  tumor  and  the  duration  of  the  symptoms. 

Prognosis:  Since  the  dynamic  aorta  is  in  itself  no  harm  to 
the  patient,  our  prognosis  is  wholly  that  of  the  underlying 
neurosis.  If  the  patient  is  sensible  and  intelligent,  a  careful 
explanation  of  his  symptoms  and  their  cause  often  produces 
a  rapid  cure  in  localized  neuroses  of  the  type  here  described. 
We  have  reason  to  hope  also  that  when  this  patient  gets  used 
to  his  false  teeth  and  is  able  to  eat  with  more  comfort,  the 
improved  nutrition  thereby  resulting  will  help  his  nervous 
condition. 

Treatment:  (see  below.  Cases  79  and  82). 


214  CASE   HISTORIES   IN   MEDICINE. 

Case  79.  A  fireman  of  twenty-six  was  exercising  engine 
horses,  riding  one  and  leading  another.  The  led  horse  fell 
and,  as  he  struggled  to  rise,  wrenched  severely  the  arm  of  the 
fireman,  who  had  not  let  go  the  halter.  He  thought  nothing 
of  it  at  the  time,  but  twenty-four  hours  later  began  to  be 
distressed  by  a  sense  of  weight  and  pressure  beneath  the 
sternum,  near  the  attachment  of  the  wrenched  pectoral. 
Under  medical  advice  he  was  laid  off  duty  and  treated  with 
liniments  and  counterirritation,  but  without  relief.  Three 
weeks'  vacation  in  the  country  benefited  him,  but  on  his 
return  to  work  he  was  unable  to  drive  or  even  to  put  on  the 
foot  brake  without  great  exhaustion.  Now  he  cannot  walk 
a  block  fast  without  feeling  tired  out  and  experiencing  a 
sense  of  pressure  under  the  sternum.  His  wife  tells  him  that 
he  moans  and  grinds  his  teeth  in  his  sleep.  He  has  lost 
fiesh,  strength,  and  color. 

The  heart's  apex  is  in  the  fifth  interspace  and  mammary 
line.  There  is  reduplication  of  the  apex  second  sound,  and 
at  the  fifth  left  costal  cartilage  a  systolic  murmur,  louder 
in  the  recumbent  position.  The  pulmonic  second  sound  is 
slightly  louder  than  the  aortic. 

Interrupted  inspiration  is  detected  in  both  fronts  and  both 
interscapular  regions,  also  transient  rales  in  the  sixth  inter- 
costal space  In  the  left  axilla.  Abdomen  negative.  The 
blood  and  urine  are  normal. 

1 .  What  is  the  usual  significance  of  moaning  and  teeth  grind- 

ing during  sleep  ?  Functional  cerebral  Irritation ;  no 
organic  disease.  Common  in  rickets  and  in  neurotic 
children.     Popular  fallacy  that  "  worms  "  are  the  cause. 

2.  How  Is  the  loss  of  flesh,  strength,  and  color  to  be  ex- 

plained ?     (See  below  under  diagnosis.) 

3.  How  are  cardiac  murmurs  affected  by  change  of  position  ? 

All  systolic  murmurs  are  louder  in  the  recumbent  posi- 
tion. Presystolic  murmurs  are  louder  in  the  erect 
position,  while  diastolic  murmurs  are  unaffected. 

The  Diagnosis  Is  traumatic  neurosis.  Aneurism  is  ex- 
cluded by  the  age,  the  acute  onset,  and  the  lack  of  evidence 
of  mediastinal  pressure.  Local  trauma  is  not  important,  for 
after   the   vacation   the  symptoms  were  general,   not   local. 


DISEASES   OF   THE   NERVOUS    SYSTEM.  215 

Chronic  latent  diseases  "  lighted  up  "  by  the  accident 
(phthisis,  anaemia,  nephritis)  are  excluded  by  the  negative 
physical  examination.  Traumatic  neurosis  is  further  sug- 
gested by  the  interval  between  the  accident  and  the  onset  of 
symptoms.  (Cerebral  haemorrhage  may  come  on  many  hours 
after  a  blow,  but  always  produces  physical  signs  of  brain 
injury,  such  as  coma,  convulsion,  paralysis  or  aphasia.) 

Prognosis:  In  cases  of  this  type  the  prognosis  depends 
very  much  upon  the  treatment.  If  the  patient  is  given  reason 
to  believe,  as  in  the  present  case,  that  some  important  local 
mischief  has  been  done,  if  he  talks  over  his  troubles  at  great 
length  with  his  friends  and  family,  and  especially  if  the  uncer- 
tainties connected  with  possible  legal  proceedings  and  damages 
weigh  upon  his  mind,  the  symptoms  may  be  prolonged  and 
the  damage  very  considerable.  An  unwise  or  unscrupulous 
physician  can  do  an  unlimited  amount  of  injury  in  such  a  case 
by  failing  to  make  light  of  the  affair,  either  because  he  does 
not  recognize  its  trivial  nature  or  because  he  does  not  wish 
to  do  so. 

If,  on  the  other  hand,  the  patient  is  reassured  from  the 
start,  his  mind  diverted  by  keeping  him  at  work,  and  avoid- 
ing local  treatment,  and  especially  if  there  is  no  question  of 
pecuniary  damages,  the  symptoms  may  very  swiftly  pass  off. 

It  is  not  the  amount  of  actual  injury  suffered  at  the  begin- 
ning, but  largely  the  psychical  elements  introduced  later  by 
the  treatment,  by  talks  with  friends,  and  by  the  expectation 
of  damages,  that  produce  the  severest  symptoms  in  these 
cases.  If  the  physician  first  sees  the  case  after  mistakes 
have  been  made,  such  as  were  exemplified  in  the  treatment 
of  this  case,  the  degree  of  his  success  in  treating  it  will  depend 
in  part  upon  the  length  of  time  since  the  accident,  and  the 
fixity  of  the  habits  of  invalidism  which  may  have  been 
acquired,  in  part  also  upon  the  physician's  ability  to  win  the 
patient's  confidence  in  himself  and  in  the  different  point  of 
view  which  must  be  adopted  if  recovery  is  to  follow. 

Treatm.ent:  I  have  indicated  in  the  foregoing  paragraphs 
what  seem  to  me  the  most  important  elements  of  treatment. 
The  patient  should  be  kept  busy,  if  not  with  his  original 
work,   then  with  some  other.     He  must  be  frequently  and 


2l6  CASE  HISTORIES   IN   MEDICINE. 

effectively  reassured,  and  urged  to  use  the  injured  part 
despite  pain.  (It  goes  without  saying  that  such  treatment 
will  do  harm  if  the  diagnosis  is  not  correct.) 

Drugs,  such  as  sodium  bromid,  lo  grains  t.i.d.,  or  trional 
10  grains  at  bedtime  in  hot  water,  may  be  needed  to  secure 
sleep.  A  bitter  tonic,  such  as  the  tincture  of  gentian  or  nux 
vomica,  may  be  useful  in  starting  appetite,  but  outdoor  life 
and  a  regular  routine,  in  which  something  is  done  at  the  same 
time  each  day,  are  more  important  both  for  sleep  and  for  appe- 
tite than  medication.  I  think  it  is  well  to  explain  to  the 
patient  the  principles  of  your  treatment  and  the  nature  of 
his  trouble.  Otherwise  he  will  wonder  why  more  is  not 
done  in  the  way  of  local  treatment. 


DISEASES    OF   THE   NERVOUS    SYSTEM.  217 

Case  80.  A  business  man,  single,  thirty-seven,  six  feet 
two  inches  tall,  weighing  246  pounds,  states  that  several  mem- 
bers of  his  family  have  had  heart  disease,  one  dying  suddenly. 
He  is  seen  March  3,  1903.  He  denies  lues,  but  has  had  five 
or  six  attacks  of  clap,  the  last  three  months  ago.  Coitus  is  not 
very  frequent.  He  drank  freely  until  three  years  ago  when 
he  had  phlebitis  in  the  left  leg.  At  this  time  he  weighed  200, 
was  treated  at  Aix-les-Bains,  lost  30  pounds,  and  felt  better 
for  it.  Since  then  he  has  taken  three  or  four  whiskeys  a  day. 
A  year  ago  he  was  under  medical  care  for  a  short  time  with 
indefinite  symptoms,  the  pulse  never  rising  above  100.  Last 
summer  he  played  27  holes  at  golf  without  inconvenience. 
In  October,  1902,  he  had  business  worries  which  kept  him 
awake  more  or  less  for  several  weeks,  and  during  this  time 
he  drank  more  freely  again.  He  takes  no  regular  exercise; 
is  fat,  flabby,  and  colorless. 

Four  days  ago  he  called  in  his  physician  for  vague  discom- 
fort in  the  upper  abdomen  and  irregular  bowels.  The  heart's 
action  was  then  regular  in  force  and  rhythm,  varying  in  rate 
from  1 60-180,  only  countable  with  the  stethoscope  over  the 
apex.  He  sleeps  with  only  one  pillow,  on  either  side,  and  has 
not  been  directly  conscious  of  his  heart,  even  on  such  exertion 
as  is  incidental  to  his  life.  In  spite  of  absolute  rest  for  four 
days,  the  heart  continues  rapid.  Temperature  normal;  urine 
negative.  He  wishes  to  get  up  and  attend  to  business.  He 
does  not  seem,  and  says  he  does  not  feel,  nervous.  The 
appetite  and  digestion  are  good  enough;  the  tongue  clean, 
the  gums  healthy.  The  heartbeats  are  quite  regular;  160 
per  minute,  counted  with  the  stethoscope,  and  the  rate  does 
not  vary  whether  he  sits,  stands,  or  lies  down.  The  cardiac 
impulse  is  visible  and  palpable  only  when  he  lies  on  his  left 
side;  it  can  then  be  localized  about  an  inch  to  the  left  of  the 
nipple,  in  the  fifth  space.  Percussion  yields  somewhat  un- 
satisfactory results  on  account  of  the  thickness  of  the  chest 
wall,  but  dulness  seems  to  extend  slightly  beyond  the  nipple 
as  he  lies  on  his  back.  The  sounds  are  clear,  save  in  the  left 
lateral  decubitus;  in  that  position,  a  slight  systolic  murmur 
is  audible  at  the  apex.  The  lungs  and  abdomen  are  negative. 
The   superficial    reflexes    are   absent;    the   knee-jerks   slight. 


2l8  CASE   HISTORIES   IN   MEDICINE. 

There  is  no  tremor.  There  is  shght  oedema  of  the  legs  and 
a  corded  vein  ( ?)  can  be  felt  in  the  left  calf.  He  wears  Boston 
garters. 

1.  What  form  of  alcoholic  drink  has  most  often  a  demon- 

strable and  permanent  effect  upon  the  heart?  Beer. 
A  hypertrophy  and  subsequent  dilatation  often  occur. 
Whiskey  usually  produces   only  temporary  weakness. 

2.  What  inference  is  suggested  by  the  absence  of  arhythmia 

in  this  case  ?  Myocardial  degeneration  usually  produces 
arhythmia.  Any  disturbance  of  cardiac  function  with 
arhythmia  is  more  serious  than  a  similar  disturbance 
without  it. 

3.  Among  the  methods  of  examination  not  yet  employed  in 

this  case,  which  are  likely  and  which  unlikely  to  yield 
valuable  information?  We  should  ascertain  whether 
the  eyes  are  prominent  or  the  thyroid  enlarged. 
These  data  will  help  to  decide  for  or  against  one  cause 
of  tachycardia  —  namely,  Graves'  disease.  The  urine 
should  be  examined.  If  it  showed  the  evidences  of 
chronic  nephritis  the  heart  symptoms  might  be  thus 
explainable.  It  would  be  valuable  to  know  how  his 
heart  reacts  to  exertion.  Organic  heart  weakness  is 
usually  increased  by  slight  exertion,  while  "  functional  " 
weakness  is  often  lessened.  If  the  "  clap  "  is  healed, 
involvement  of  the  heart  in  this  infection  becomes  un- 
likely. Blood-pressure  measurements,  if  normal,  would 
be  reassuring.  If  he  uses  tobacco  to  excess  the  symp- 
toms may  be  due  to  this  cause.  Blood  examination 
would  probably  yield  no  important  information. 

4.  Has  the  venereal  history  any  relation  to  the  present  symp- 

toms? Probably  not.  Gonorrhoeal  endocarditis  or 
myocarditis  produces  fever  and  usually  more  definite 
evidences  of  valvular  deformity;  further,  his  gonorrhoea 
is  apparently  healed. 

5.  Causes  and  types  of  tachycardia?     Any  physical  or  emo- 

tional activity,  many  infectious  diseases,  neurotic  and 
toxic  states,  cardiac  weakness  and  dilatation  from  any 
cause,  Graves'  disease,  "paroxysmal  tachycardia." 

Diagnosis:  There  was  no  exophthalmos  or  goiter;  the  urine 
was  normal;  tobacco  was  used  to  excess;  the  gonorrhoea  was 
healed;  blood  pressure  was  normal  and  was  increased  (not 
decreased)  by  exertion.  It  should  be  noted  that  the  position 
of  the  palpable  apex  beat  was  normal  for  the  position  in  which 
the  patient  lay.     The  attack  is  rather  too  long  to  be  classed  as 


DISEASES   OF    THE   NERVOUS   SYSTEM.  2ig 

"  pciroxysmal  "  tachycardia  of  the  ordinary  type,  yet  I  can 
make  no  better  diagnosis  than  "  atypical  paroxysmal  tachy- 
cardia." There  is  no  evidence  of  infection  or  of  cardiac  dila- 
tation. A  subjective  ''sense  of  well  being,"  such  as  is  here 
present,  is  not  often  seen  in  organic  heart  lesions  with  tachy- 
cardia. 

There  is  no  evidence  of  passive  congestion  anywhere,  for  in 
a  fat  man  slight  oedema  of  the  legs  is  physiological,  especially 
with  varicose  veins  such  as  appear  to  be  here  present.  Hence 
we  have  no  considerable  heart  weakness.  A  combination  of 
toxic  and  neurotic  factors,  due  to  the  effect  of  an  excess  of 
tobacco  (and  perhaps  alcohol)  on  an  otherwise  healthy  but 
neurotic  individual,  seems  the  probable  cause  of  the  paroxysm 
in  this  case. 

Prognosis:  Death  almost  never  occurs  in  the  paroxysm. 
It  is  important  that  the  patient  should  know  this.  The 
majority  of  people  who  have  had  one  such  attack  will  have 
others  in  the  course  of  their  lives,  though  this  is  by  no  means 
invariable.  As  a  rule  the  attacks  last  a  few  hours  and  then 
cease  as  suddenly  as  they  began.  Occasionally  they  may  be 
prolonged  over  several  days.  Beyond  this  the  prognosis  de- 
pends upon  the  underlying  lesion,  if  any  such  lesion  is  present. 
In  the  cases  complicating  a  functional  neurosis,  the  prog- 
nosis is  that  of  the  neurosis.  I  have  known  such  an  attack 
to  come  on  in  a  dentist's  chair  in  a  woman  nervously  unstrung 
by  the  presence  of  the  menstrual  period.  Here  the  attack 
was  wholly  and  instantaneously  removed  by  the  onset  of 
nausea  and  vomiting.  In  another  case  initiated  by  alco- 
holism and  domestic  recriminations  therefrom  resulting,  the 
attack  ceased  suddenly  soon  after  the  nerves  of  the  patient 
and  her  family  had  been  soothed.  Cases  which  complicate 
organic  disease  of  the  heart  are  of  course  much  more  serious, 
and  it  is  doubtful  whether  they  should  be  classified  under  the 
heading  of  paroxysmal  tachycardia.  The  case  here  exem- 
plified is  decidedly  atypical,  yet  probably  belongs  under 
the  general  heading  of  paroxysmal  tachycardia  unusually 
prolonged. 

Treatment:  One  of  the  most  successful  methods,  which  in 
a  number  of  cases  has  been  repeatedly  and  promptly  efTectual, 


220  CASE   HISTORIES   IN   MEDICINE. 

is  that  of  lowering  the  patient's  head  and  elevating  his  body 
and  legs  until  he  is  practically  standing  on  his  head.  A 
physician  who  experienced  the  trouble  in  his  own  person 
recently  reported  that  brisk  walking  would  quickly  abolish 
the  trouble  in  his  case.  I  have  already  mentioned  that  the 
occurrence  of  vomiting  sometimes  checks  the  paroxysms. 
Heart  tonics  and  stimulants  seem  to  be  without  avail,  and  in 
many  cases  one  has  to  wait  for  the  spontaneous  termination 
of  the  paroxysm. 


DISEASES  OF   THE   NERVOUS   SYSTEM.  221 

Case  8i.  A  judge  of  seventy-five  consulted  his  physician 
June  10,  19 10,  complaining  that  his  appetite  (always  rather 
meager)  had  been  gradually  failing  all  winter,  although  he 
had  felt  perfectly  well  and  done  his  work  on  the  bench  until 
April  I,  when  his  appetite  absolutely  left  him.  A  week's 
vacation  on  his  farm  was  of  no  apparent  benefit  and  he  re- 
sumed work,  subsisting  wholly  on  milk,  eggs,  and  oatmeal 
gruel  which  he  still  manages  to  force  down.  During  the 
period  since  April  i  he  lost  his  enjoyment  of  tobacco,  but 
within  the  last  few  days  this  has  returned  and  he  now  smokes 
with  relish. 

There  is  no  indigestion,  no  pain,  no  disturbance  of  the 
bowels  or  of  the  power  to  sleep.  Naturally  enough  he  feels 
rather  weak  as  he  takes  only  from  three  to  six  eggs  daily 
with  less  than  a  pint  of  milk  daily,  and  a  few  teaspoonfuls  of 
oatmeal  gruel. 

His  usual  weight  is  170;  his  present  weight  155.  For  a 
month  he  has  had  cough  (an  unusual  thing  for  him)  with 
sputa.     There  has  been  no  sense  of  fever  or  chilliness. 

Physical  examination  was  wholly  negative  save  for  thicken- 
ing and  tortuosity  of  the  radials  and  a  few  transient  rales 
above  and  below  the  right  clavicle  in  front.  Temperature 
99°.  Sputa  negative.  Haemoglobin  90%.  Blood  pressure 
160.     Urine  negative. 

Diagnosis:  Among  the  diseases  that  may  produce  such  an 
anorexia  are  gastric  cancer,  anaemia  of  any  type,  tubercu- 
losis, nephritis,  arteriosclerosis,  and  the  unknown  infections 
known  as  "  common  colds." 

Anaemia,  heart  trouble,  and  nephritis  are  excluded  by  the 
results  of  the  examination  above  recorded.  Tuberculosis  was 
seriously  considered  but  repeated  sputum  exajninations  were 
negative,  and  after  the  first  visit  no  abnormal  signs  could  be 
detected  in  the  chest. 

Gastric  cancer  could  not  be  excluded  although  there  was 
no  tumor,  no  evidence  of  stasis,  no  pain  or  vomiting. 

The  course  of  the  case  made  it  seem  probable  that  the 
moderate  arteriosclerosis  from  which  he  was  suffering  when 
I  first  saw  him  was  responsible  for  most  of  his  symptoms. 
Probably  his  "  bad  cold  "  accounted  for  the  rest. 


222  CASE    HISTORIES   IN   MEDICINE. 

Prognosis:  Gradual  restoration  of  appetite  and  strength 
is  to  be  expected  but  it  is  probable  that  the  anorexia  will 
return  from  time  to  time  as  it  not  infrequently  does  in  elderly 
people  with  or  without  an  obvious  cause. 

Treatment:  Outdoor  life  without  much  exercise,  a  bitter,  and 
an  exhortation  to  patience  are  the  essentials.  The  patient  must 
force  down  all  the  food  he  can.  The  appetite  may  be  tempted 
by  dehcacies  of  various  kinds  —  fruits,  jellies,  shellfish;  the 
details  of  cooking  and  serving  are  important.  In  this  case 
there  has  been  no  return  of  appetite  up  to  date  (November  i , 
1911).  In  June,  1911,  there  was  a  slight  "shock"  with 
right  hemiparesis  and  aphasia,  all  of  which  disappeared  in 
two  weeks.  The  patient  has  been  steadily  at  work  and  feels 
in  most  respects  very  well. 


DISEASES   OF   THE   NERVOUS    SYSTEM.  223 

Case  82.  A  school  teacher,  single,  twenty-four  years  old, 
seen  April  9.  Family  history  unimportant.  Never  strong. 
Scarlet  fever  and  measles  in  childhood.  Brain  fever  at  nine, 
pneumonia  at  thirteen,  ner^'^ous  prostration  at  sixteen,  "  con- 
gestion of  the  brain  and  spinal  cord  "  at  nineteen,  from  over- 
work at  college.  One  year  ago  was  laid  up  for  two  months 
by  a  "general  breakdown,"  Last  summer  broke  down  with, 
she  says,  "every  symptom  of  pulmonary  tuberculosis." 
Catamenia  irregular,  five  weeks  to  three  or  four  months; 
appeared  last  ten  days  ago.  Has  taught  night  school  in  addi- 
tion to  her  regular  work  since  October,  and  since  December 
has  had  a  series  of  colds  with  cough  and  some  expectoration. 
Has  complained  of  general  lassitude  until  the  afternoon,  when 
she  feels  fairly  well.  Six  weeks  ago  was  called  home  to  nurse 
her  mother  in  her  last  illness,  apoplexy.  Returned  ten  days 
ago  all  used  up.  Two  days  later  found  that  she  was  suddenly 
unable  to  distinguish  letters  in  the  book  she  was  reading.  She 
rose  to  call  for  help  and  fell.  Was  conscious  when  found, 
but  unable  to  assist  herself.  Had  a  series  of  convulsions 
during  the  night  and  was  kept  under  ether  by  her  attending 
physician.  Since  then  she  has  felt  tired  and  weak  with  con- 
stant headache,  but  has  not  been  confined  strictly  to  bed. 
No  appetite.  Bowels  constipated.  Her  eyesight  has  re- 
turned. About  half  an  hour  ago  she  was  found  in  the  follow- 
ing condition: 

A  thin,  delicate,  half-starved  looking  girl,  apparently  un- 
conscious, lying  fiat  on  her  back  in  bed,  motionless,  except 
for  some  tremor  of  the  eyelids.  She  is  so  rigidly  extended 
that  with  the  hand  beneath  her  neck  she  can  be  lifted  like  a 
log  until  she  rests  only  on  her  heels.  Her  feet  are  extended 
to  the  utmost  with  the  toes  in  plantar  flexion.  Her  arms 
and  hands  are  rigidly  extended  and  held  close  to  her  sides, 
but  can  be  bent  by  persistent  pressure.  When  released 
they  immediately  resume  their  former  position.  The  fingers 
are  extended  and  abducted  (the  "  accoucheur's  hand  ").  The 
acetone  odor  of  the  breath  can  be  detected  several  feet  away. 
Loud  calls,  pinching,  pricking  with  a  pin  produce  no  response 
except  an  occasional  flickering  of  the  eyelids.  When  the 
hand  is  placed  closely  over  her  nose  and  mouth  she  struggles 


224  CASE   HISTORIES   IN   MEDICINE. 

until  freed.  The  condition  of  the  pupils,  which  probably 
react  to  light,  is  made  out  with  difficulty  as  the  eyelids  re- 
sist attempts  to  open  them.  The  eyes  are  turned  upward. 
Heart,  lungs,  and  abdominal  viscera  seem  normal.  Tem- 
perature 99°.  Pulse  no,  soft,  easily  compressed.  Respira- 
tion normal.  Urine,  35  ounces,  normal  color,  acid,  specific 
gravity  1022.  Albumin,  very  slight  trace.  Sugar  absent. 
Ferric  chlorid  test  positive.  Sediment  contains  a  rare  hyalin 
and  finely  granular  cast.     Hg  90%.     Whites  9000. 

1 .  What  guess  can  we  make  regarding  the  nature  of  her  early 

illnesses  ?  As  a  rule,  a  history  of  this  kind  turns  out  to 
mean  neurasthenia. 

2.  What  is  the  general  significance  of  an  improvement  of  all 

symptoms  in  the  afternoon  ?  If  symptoms  are  regularly 
worse  in  the  afternoon,  what  should  be  suspected  ? 
Anaemic  patients  and  neurasthenics  are  apt  to  be  better 
in  the  latter  part  of  the  day.  Patients  who  are  worse 
in  the  afternoon  often  have  fever  (tuberculosis,  malaria, 
typhoid),  but  simple  fatigue  may  be  the  cause. 

3.  Significance   of   tremor   of   the   eyelids?     Its   distinction 

from  habit  chorea  and  other  facial  spasms?  Usually 
hysterical  or  neurotic.  The  motions  are  finer  and  more 
continuous  than  any  other  spasm. 

4.  Under  what  conditions  is  the  ferric  chlorid  test  in  the 

urine  to  be  obtained  ?  {a)  Whenever  carbohydrate 
food  is  not  adequately  utilized.  This  may  be  because 
it  is  not  ingested  or  not  retained  (as  in  starvation,  pro- 
longed vomiting,  or  rectal  alimentation),  because  it  is 
not  absorbed  (diarrhoea,  tuberculous  peritonitis)  or  not 
metabolized  (diabetes).  In  this  case  the  semi-starvation 
readily  explains  the  reaction,  {b)  In  a  few  conditions 
the  ferric  chlorid  test  cannot  be  so  explained  —  e.g.,  on 
a  salt-free  diet  the  reaction  has  been  found  to  be  strongly 
marked. 

Diagnosis:  With  a  negative  physical  examination  (except 
for  the  urine  which  yields  no  information  of  diagnostic  value) 
the  diagnosis  probably  lies  between  the  following  alternatives : 
Epilepsy,  hysteria,  meningitis,  autointoxication. 

Epilepsy  is  suggested  by  the  history  of  convulsions ;  against 
it  are  all  the  facts  of  the  present  condition  and  most  of  those 
in  the  past  history  which  point  strongly  to  hysteria.  Hysteria 
often  follows  upon  just  such  a  history  of  neuroses  in  youth, 


DISEASES   OF   THE   NERVOUS    SYSTEM.  225 

physical  and  psychical  exhaustion,  and  mistaken  treatment 
(etherization).  The  tendency  to  opisthotonos  and  tonic  con- 
ditions of  the  extremities,  the  tremor  of  the  lids  and  rolling 
up  of  eyeballs,  the  fact  that  she  can  be  roused  to  purposeful 
action  by  appropriate  stimuli  (covering  her  mouth  and  nose) 
despite  anaesthesia  to  a  pin  prick  —  all  point  strongly  to 
hysteria. 

Meningitis  may  exist  without  temperature  or  leucocytosis 
(though  it  usually  produces  both),  but  cannot  be  diagnosed 
unless  headache,  retraction  of  the  neck,  changes  in  the  spinal 
fluid  and  eye  symptoms  (squint,  ptosis,  papillary  or  retinal 
changes)  are  present. 

Autointoxication  is  very  possibly  present  in  all  hysteria, 
and,  in  view  of  the  starvation  that  is  probably  an  element 
in  this  case,  it  is  not  unlikely  that  the  system  is  in  some  way 
poisoning  itself,  but  such  theories  are  not  at  present  capable 
of  clinical  verification. 

Prognosis:  The  outlook  in  this  case  will  probably  be 
better  than  in  many  other  cases  of  hysteria,  because  there 
are  more  removable  etiological  factors.  In  the  first  place, 
she  has  had  a  great  deal  of  physical  and  mental  strain  from 
which  she  needs  to  be  rested.  After  such  a  thorough  rest 
there  is  reason  to  believe  that  her  nervous  system  will  behave 
itself  better,  regardless  of  any  other  treatment.  Then  there 
is  reason  to  believe  that  she  has  not  been  properly  nourished, 
and  a  reversal  of  the  policy  that  has  led  to  her  present  half- 
starved  condition  may  be  expected  to  help  her  mental  symp- 
toms as  well  as  her  bodily  condition.  Thirdly,  we  can  certainly 
improve  upon  the  treatment  of  the  convulsions.  Nothing 
worse  could  be  done  for  them,  I  think,  than  to  etherize  the 
patient.  A  policy  of  neglect  is  essential.  The  more  attention 
paid  to  such  manifestations,  the  more  severe  they  become. 

Treatment:  After  the  removal  of  the  three  factors  just 
mentioned,  we  should  endeavor  to  find  out  whether  there  is 
any  "  ingrowing  thought  "  or  any  reason  for  brooding.  Thor- 
oughly to  talk  out  with  someone  in  whom  she  has  confidence, 
the  most  important  experiences  of  her  life,  especially  the 
painful  experiences,  is  often  an  essential  element  at  the  begin- 
ning of  treatment.     Beyond  this  the  treatment  is  essentially 


226  CASE   HISTORIES   IN   MEDICINE. 

that  given  by  most  physicians  at  the  present  time  for  the 
group  of  conditions  classified  as  psychoneuroses,  namely, 
hysteria,  neurasthenia,  psychasthenia,  traumatic  and  visceral 
neuroses. 

It  is  now  generally  recognized  that  the  essential  element 
in  the  treatment  of  these  diseases  is  to  arouse  and  maintain 
a  live  interest  in  some  sort  of  work. that  will  lead  to  regular 
routine  and  a  sense  of  achievement.  The  work  cure  is  not 
the  whole  of  our  treatment  in  such  cases.  We  must  also  do 
something,  if  we  can,  to  provide  for  some  more  satisfactory 
recreation  than  has  usually  come  into  the  patient's  life,  and 
for  some  proper  outlet  for  her  affections.  Nevertheless, 
work  is  the  foundation  for  both  of  these  other  elements. 
Unless  the  patient  can  be  regularly  and  interestingly  em- 
ployed, she  will  get  comparatively  little  good  out  of  recrea- 
tion, while  her  personal  relationships  are  not  likely  to  be 
permanent  or  satisfactory. 

Medicine  has  in  my  opinion  no  considerable  part  in  the 
treatment  of  these  patients.  Our  problem  is  an  educational 
one. 


DISEASES   OF    THE   NERVOUS   SYSTEM.  22/ 

Case  83.  A  bookkeeper  of  twenty- five  entered  the  hospital 
March  28,  191 1.  The  family  history  and  past  history  re- 
vealed nothing  of  importance. 

For  the  past  year  she  has  tired  more  easily  than  before, 
but  has  kept  at  work  and  considers  herself  fairly  well.  Six- 
teen days  before  entrance  she  appeared  in  her.  usual  health 
and  went  to  church  in  the  morning.  Soon  after  entering 
the  church  she  fell  unconscious,  vomited,  and  had  a  general 
epileptiform  convulsion  lasting  a  few  minutes.  Coma  and 
vomiting  continued  until  6  p.m.  Next  day  she  was  con- 
scious but  weak.  After  a  week's  rest  in  bed,  vomiting  ceased 
and  two  days  later  she  was  able  to  go  outdoors.  On  the 
eleventh  day  after  her  attack  she  was  feeling  nearly  well 
when,  on  getting  up  from  a  chair,  she  again  fell  unconscious. 
Since  that  time  she  has  been  in  a  condition  of  semiconscious- 
ness, speaking  only  when  spoken  to,  vomiting  frequently, 
and  complaining  of  severe  headache.  There  has  been  no 
paralysis  and  no  disturbance  of  the  sphincters.  The  vomitus 
has  shown  nothing  of  interest. 

The  patient  is  well-nourished  and  has  a  good  color.  The 
pupils  are  slightly  irregular  but  equal  and  react  normally.  The 
limit  of  palpable  cardiac  impulse  is  in  the  fourth  space  10  cm. 
to  the  left  of  the  mid-sternum,  2  cm.  outside  of  the  median 
line.  The  action  is  regular,  the  sounds  of  good  quality,  and 
no  murmurs  audible.  Pulse  and  arterial  walls  show  nothing 
abnormal.  There  are  a  few  scattered  squeaking  rales  in  the 
backs  of  both  lungs.  The  abdomen  is  negative.  Knee-jerks 
cannot  be  obtained  even  on  reenforcement.  The  plantar 
reflex  is  normal. 

Systolic  blood  pressure  140.  Haemoglobin  95%.  Leuco- 
cytes 11,000,  the  smear  showing  slight  polynuclear  leuco- 
cytosis.  Twenty-four-hour  amount  of  urine  was  from  20  to 
35  ounces,  the  specific  gravity  in  the  neighborhood  of  1018, 
a  slight  trace  of  albumin,  no  sugar.  Sediment  shows  a  rare 
hyalin  cast.     Retinal  examination  showed  choked  disks. 

Three  days  after  entrance  the  patient  had  another  general 
convulsion  and  both  sphincters  became  relaxed.  Soon  after 
this  a  slight  left  facial  paresis  appeared  and  both  external 
recti  showed  some  insufficiency,  most  marked  upon  the  left. 


228  CASE   HISTORIES   IN   MEDICINE. 

There  was  some  difficulty  in  swallowing,  though  the  muscles 
of  the  tongue  were  not  disturbed.  The  knee-jerks  continued 
absent  and  the  plantars  normal. 

Diagnosis:  Cerebral  haemorrhage,  cerebral  syphilis,  and 
brain  tumor  are  the  most  probable  diagnoses.  There  is  no 
sufficient  change  in  the  urine  or  the  heart  to  make  us  con- 
sider ursemia  seriously.  In  my  experience,  moreover,  uraemia 
never  appears  out  of  a  clear  sky  with  such  stormy  symptoms 
as  are  present  in  this  case.  The  absence  of  fever  makes  it 
possible  to  exclude  meningitis,  especially  as  there  is  no  re- 
traction of  the  head  or  no  increased  tension  of  the  hamstring 
muscles. 

Cerebral  haemorrhage  is  very  unusual  at  this  patient's  age. 
In  a  person  past  fifty  it  would  seem  the  obvious  diagnosis, 
especially  if  the  blood  pressure  were  high.  Furthermore, 
the  changes  in  the  optic  disks  are  not  characteristic,  and  the 
absence  of  paralysis  would  be  difficult  to  explain.  In  the 
absence  of  any  history  or  lesions  pointing  to  syphilitic  infec- 
tion we  have  no  special  reason  to  suspect  syphilis,  but  this 
disease  cannot  be  excluded  especially  as  no  Wassermann  re- 
action has  been  attempted  and  no  spinal  puncture  made. 

The  condition  of  the  optic  disks  and  the  age  of  the  patient 
suggest  brain  tumor.  The  suddenness  of  onset,  though  not 
typical  of  that  disease,  is  by  no  means  uncommon  in  it,  since 
the  vascular  forms  of  cerebral  neoplasm  may  remain  alto- 
gether latent  and  symptomless  until  haemorrhage  from  one 
of  the  friable  vessels  produces  a  picture  like  that  seen  in  this 
case.  This  was  in  fact  the  condition  found  somewhat  later 
at  autopsy. 

Prognosis :  Despite  the  improvements  in  surgical  technique, 
it  remains  true  that  the  outlook  for  the  vast  majority  of  cases 
of  brain  tumor  is  quite  hopeless,  since  the  growth  is  usually 
an  infiltrating  one  and  incapable  of  surgical  removal.  The 
operation  of  decompression  may  prolong  a  patient's  life  and 
increase  his  comfort  for  many  months,  but  with  the  present 
state  of  the  science  of  cerebral  localization  even  decompres- 
sion proves  of  little  value  in  the  hands  of  many  surgeons. 

Treatment:  All  patients  should  be  given  mercury  and 
potassic  iodid  because  the  possibility  of  syphilis  can  rarely 


DISEASES   OF   THE   NERVOUS    SYSTEM.  229 

be  excluded.  This  was  done  in  the  present  case  and  the 
iodid  was  pushed  until  a  dermatitis  appeared,  but  without 
benefit. 

Otherwise  than  this,  our  only  resource  is  surgical  inter- 
ference. In  the  present  case  subtentorial  decompression  re- 
vealed nothing.  A  supratentorial  opening  was  then  made 
upon  the  left.  Two  days  later  the  patient's  headache  was 
much  better  and  both  optic  disks  showed  improvement,  the 
right  returning  almost  to  normal.  The  knee-jerks  reappeared, 
though  they  were  rather  slight,  especially  upon  the  left.  The 
patient  died  twenty-two  days  after  operation. 

Autopsy  showed  a  soft  vascular  tumor  in  the  right  parietal 
lobe  near  the  base  of  the  brain. 


230  CASE   HISTORIES   IN    MEDICINE. 

Case  84.  Mrs.  M.,  fifty-one,  is  seen  August  9,  1905.  She 
has  been  in  bed  since  July  4,  suffering  from  "  a  complication 
of  diseases,"  and  her  medical  attendant  has  been  changed 
several  times. 

She  had  nervous  prostration  fourteen  years  ago,  and  has 
never  been  well  since,  but  except  for  children's  diseases  she 
has  had  no  other  definite  illness.  She  has  had  eight  children 
—  the  last  six  years  ago  —  and,  until  recently,  has  done  most 
of  the  housework  for  the  whole  family. 

Her  present  illness  began  July  4  with  diarrhoea,  vomiting, 
fever,  and  sweating.  These  symptoms  passed  off  in  about 
three  weeks,  but  there  have  been  suggestions  of  a  return  of 
them  several  times,  and  she  has  not  regained  her  full  strength. 
Insomnia  is  a  very  troublesome  symptom,  and  in  the  long, 
wakeful  hours  she  sometimes  has  spells  of  "  weakness,"  for 
which  aromatic  spirits  of  ammonia  is  taken  with  some  relief. 
There  are  also  "  smothering  spells  "  when  she  feels  as  if  she 
must  get  up  and  walk,  and  is  restrained  only  by  the  strict 
orders  of  her  physician. 

She  has  never  been  a  hearty  eater,  but  the  appetite  is  now 
very  fair.  There  is  no  pain  and  the  bowels  move  with  the 
aid  of  laxatives. 

Examination  showed  a  stout,  pale  woman,  with  a  tem- 
perature of  99°.  The  size  of  the  heart  could  not  be  exactly 
determined  on  account  of  fat,  but  the  sounds  were  normal 
and  were  loudest  in  their  normal  sites.  The  peripheral  arter- 
ies were  normal.  At  the  beginning  of  the  examination  fine 
crackles  were  heard  at  the  base  of  each  axilla,  but  they  dis- 
appeared after  a  few  deep  breaths  and  were  not  heard  again. 
Liver  dulness  began  at  the  seventh  rib,  and  the  edge  of  the 
organ  could  be  felt  below  the  ribs.  Otherwise  visceral  exam- 
ination was  negative.     Haemoglobin  90%.     Urine  normal. 

Diagnosis:  A  feverish  gastro-enteritis  five  weeks  ago;  now 
weakness,  insomnia,  and  smothering  spells,  with  a  desire  to 
move  about  —  such  are  the  main  complaints.  In  a  woman 
of  fifty-one  these  symptoms  suggest  arteriosclerosis  or  myo- 
carditis, but  the  physical  examination  gives  no  support  to 
these  diagnoses,  and  without  physical  signs  one  cannot  make 
them.     The  crackles  in  the  lungs  would  have  been  significant 


DISEASES   OF   THE   NERVOUS   SYSTEM.  23 1 

had  they  persisted,  but  transient  crackles  at  base  of  the  axilla 
have  no  pathological  significance.  The  liver  is  low  —  both 
the  upper  and  the  lower  border  —  but  shows  no  evidence  of 
enlargement,  and  simple  ptosis,  whether  of  the  liver  or  of  all 
the  abdominal  organs,  is  not  likely  to  explain  the  symptoms 
of  this  case.  The  main  question  is:  Has  the  woman  any  dis- 
ease at  all  ?  Are  not  her  weakness  and  insomnia  the  result 
of  staying  in  bed  ?  This  hypothesis  was  in  fact  verified  by 
the  results  of  getting  up  and  to  work.  In  a  few  weeks  the 
woman  was  perfectly  well. 

Prognosis:  Under  judicious  treatment  this  patient  should 
recover  more  quickly  than  most  psychoneurotics,  for  the 
origin  of  her  troubles  is  comparatively  simple  and  recent. 
She  has  got  hipped  upon  herself  by  staying  in  bed  too  long. 
When  she  has  got  up  and  finds  that  she  is  able  to  work  and 
enjoy  herself,  she  should  rapidly  recover.  Of  course  the 
underlying  depression  which  made  her  have  nervous  prostra- 
tion fourteen  years  earlier,  and  made  her  liable  to  such  an 
attack  as  the  present,  will  remain  and  will  make  it  probable 
that  in  one  form  or  another  she  will  have  to  resist  similar 
types  of  prostration,  if  she  does  not  fall  a  victim  to  them. 
But  for  the  present,  under  a  reversal  of  the  treatment  pre- 
viously pursued,  she  should  promptly  recover. 

Treatment:  Essentially  that  mentioned  in  the  previous 
case. 


232  CASE   HISTORIES   IN   MEDICINE. 

Case  85.  A  tall  boy  of  nineteen  is  brought  to  the  physi- 
cian's office  by  his  mother,  who  states  that  for  ten  years  he 
has  had  trouble  with  his  head  and  with  his  bladder.  Usu- 
ally he  has  to  pass  water  every  two  hours  in  the  daytime. 
This  summer  while  he  was  in  the  country  the  intervals  were 
longer,  three  or  four  hours,  and  his  headache  did  not  trouble 
him,  but  since  the  autumn  the  headache  has  returned.  It  is 
in  various  parts  of  the  head,  and  goes  and  comes. 

The  urine  is  sometimes  turbid,  but  never  hurts  him  during 
micturition.  Masturbation  was  rather  frequent  six  years 
ago,  but  has  not  been  practised  since,  he  says.  His  father's 
sister  and  his  father's  aunt  died  of  "  softening  of  the  brain," 
and  his  mother  is  anxious  about  his  mental  condition.  Appe- 
tite, digestion,  and  sleep  good.     Bowels  regular. 

Examination  shows  a  rather  shame-faced,  neurotic  boy, 
very  tall  for  his  age.  Visceral  examination  is  negative. 
Blood  normal.  Urine  1026,  slightly  high-colored,  very  acid, 
no  shreds.     No  albumin,  no  sugar. 

1.  What  are   the  bad   effects   of   masturbation?     In   many 

cases  there  are  no  demonstrable  ill  effects  whatever. 
In  a  few  cases  the  youth  seems  to  be  debilitated  by  it. 
That  it  ever  produces  brain  disease  is  very  unlikely. 
It  is  a  symptom,  not  a  cause  of  mental  enfeeblement. 
In  many  boys  a  neurosis  is  produced  by  the  shame  and 
remorse  associated  with  it  and  by  fear  of  its  terrible 
consequences  as  they  are  (quite  falsely)  delineated  in 
quack  newspaper  advertisements  or  by  friends  and 
parents.  This  neurosis  entails  insomnia,  anorexia,  con- 
stipation, emaciation,  and  may  thus  bring  about  a 
pitiable  condition. 

2.  Common  causes  of  frequent  micturition  in  youth?     Ner- 

vousness (especially  in  girls),  hyperacid  urine,  the  irri- 
tation of  a  phimotic  foreskin  or  of  retained  smegma, 
gonorrhoea,  cystitis,  diabetes  (either  type). 

Diagnosis:  When  a  headache  recurs  in  the  autumn  (when 
school  begins)  after  disappearing  in  summer,  eyestrain  should 
be  suspected  and  looked  for.  In  this  case  it  was  found  and 
under  proper  treatment  greatly  improved.  Maternal  anxiety 
doubtless  contributed  considerably  to  the  boy's  symptoms 
in  this  as  in  so  many  other  cases,  and  by  reassuring  her  a 


DISEASES   OF   THE   NERVOUS   SYSTEM.  233 

good  effect  was  produced  upon  the  boy.  The  urinary  trouble 
seemed  to  be  due  to  hyperacidity;  at  any  rate  it  improved 
rapidly  under  the  administration  of  sodic  bicarbonate  half  a 
drachm  t.i.d.  None  of  the  other  causes  of  frequent  micturi- 
tion mentioned  above  were  found  in  this  case. 

Eyestrain,  hyperacid  urine,  and  an  overanxious  mother  were 
apparently  the  causes  of  his  trouble. 

Prognosis:  With  removal  of  these  hindrances  to  normal 
development  the  boy  should  rapidly  regain  his  health.  No 
doubt  he  has  outgrown  his  strength  and  owing  to  this  fact 
he  will  need  some  years  to  attain  vigor. 

Treatment:  The  essentials  have  been  mentioned  already. 
Beside  correcting  his  eye  troubles,  modifying  the  acidity  of 
his  urine,  and  reassuring  his  mother,  one  should  encourage 
him  to  outdoor  life,  early  hours,  and  nutritious  food.  No 
drugs  seem  indicated. 


234  CASE   HISTORIES   IN   MEDICINE. 

Case  86.  A  clergyman,  sixty  years  old,  gave  the  follow- 
ing account  of  his  case.  Since  he  began  to  preach  he  has 
been  subject  to  insomnia,  but  it  is  under  his  control  unless 
he  is  excited  by  mental  labor,  the  effects  of  which  are  most 
marked  when  it  occupies  the  evening.  Eyes  weak  for  forty 
years,  but  no  worse  of  late.  Though  the  voice  is  clear,  its 
use  in  lecturing  or  preaching  is  at  times,  when  he  is  debilitated, 
somewhat  painful  and  requires  much  exertion.  Appetite 
good,  but  two  to  three  hours  after  eating  he  sometimes  has 
a  kind  of  epigastric  pain  or  feeling  of  heat,  not  dependent 
on  amount  or  character  of  food,  unless  it  be  worse  when  he 
eats  little.  Ice  water  seems  to  touch  a  raw  spot.  Bowels 
tend  to  constipation  since  early  childhood.  For  many  years 
has  been  troubled,  especially  when  he  is  debilitated,  by  a 
sensation  over  the  whole  body  as  if  pricked  by  innumerable 
needles. 

Four  years  ago,  while  much  exhausted  by  mental  labor, 
went  to  a  watering  place,  where  he  was  put  on  low  diet, 
reducing  remedies,  and  frequent  baths.  At  the  end  of  four 
months,  while  at  breakfast,  was  attacked  with  vertigo  and 
began  to  talk  with  great  volubility  but  incoherently.  For 
three  days,  which  were  a  blank  to  him,  his  condition  excited 
much  alarm,  but  at  the  end  of  that  time  his  mind  became 
clear  and  there  has  been  no  return  of  symptoms  since.  There 
was  numbness  of  the  hands  and  feet  at  time  of  the  attack. 

In  the  two  last  years  has  had  five  attacks  of  pain  in  upper 
abdomen,  without  known  cause,  very  severe  and  accompanied 
by  distention  and  general  perspiration.  One  of  these  came 
on  after  conducting  an  examination  four  hours  long,  another 
after  eating  hastily.  Otherwise  no  cause  known.  Pain 
generally  began  at  9  p.m.,  and  lasted  till  midnight.  No  other 
symptoms  noticed  before,  during,  or  after  the  attack  of  pain. 

1.  For  what  should  one  search  especially  in  making  a  physi- 

cal examination  of  this  patient?  The  stigmata  of 
hysteria,  arteriosclerosis,  the  signs  of  tabes  or  dementia 
paralytica  (pupils,  knee-jerks,  speech-writing,  mental 
condition). 

2.  What  gastric  anomaly  do  the  digestive  symptoms  suggest? 

Hyperchlorhydria. 


DISEASES   OF   THE  NERVOUS    SYSTEM.  235 

3.  If  his  gastric  symptoms  had  appeared  for  the  first  time 

within   a  year  what   diagnoses   should   be  considered  ? 
Gastric  cancer,  gall-stones. 

4.  Name  the  most  important  causes  of  paroxysmal  epigastric 

pain.     Peptic  ulcer,  gall-stones,  appendicitis,  plumbism, 
tabes,  malaria,  uraemia,  and  pancreatitis. 

Diagnosis;  Since  physical  examination  was  negative  and 
the  patient  was  able  to  work  hard  despite  his  many  symptoms, 
the  diagnosis  of  neurasthenia  was  made;  the  improvement 
under  treatment  suited  to  that  condition  confirmed  the  diag- 
nosis. The  attack  at  the  watering-place  was  apparently  due 
to  cerebral  anaemia,  the  result  of  wrong  treatment. 

Prognosis:  This  patient  is  not  much  sick  but  one  cannot 
promise  with  any  certainty  that  he  will  be  much  better.  The 
habits  of  mind  and  body  which  he  has  acquired  in  the  course 
of  his  sixty  years  are  not  likely  to  be  very  far  modified.  An 
attempt,  however,  -may  be  made  along  the  lines  indicated  in 
the  next  paragraph. 

Treatment:  To  check  the  attacks  of  epigastric  pain  is  our 
chief  task,  since  most  of  his  other  symptoms  are  either  trivial 
or  matters  of  past  history.  He  should  be  advised  to  eat 
small  meals  at  intervals  of  about  two  hours,  avoiding  meat 
and  salt,  and  never  allowing  his  stomach  to  become  empty 
or  his  hunger  excessive.  He  should  be  ordered  to  eat  slowly 
and  chew  his  food  well,  also  to  avoid  such  strains  as  are  men- 
tioned in  the  last  paragraph  of  his  own  account.  At  his  age 
evening  work  should  be  avoided,  both  on  account  of  its  tend- 
ency to  produce  insomnia,  and  because  his  stomach  is  more 
likely  to  get  upset  at  this  time  of  the  day. 


CHAPTER  VII. 

DISEASES    OF   LYMPHATIC    AND    DUCTLESS 
GLANDS. 

Case  87.  A  married  woman  of  fifty  has  had  three  children, 
the  youngest  seventeen,  no  miscarriage,  and  has  passed  the 
menopause  without  disturbance.  Soon  after  the  birth  of  her 
second  child  she  became  unconscious  with  dilated  pupils,  had 
convulsions,  right  hemiplegia  and  aphasia,  but  recovered  en- 
tirely. Her  domestic  life  has  not  been  happy  for  some  years. 
During  the  eighteen  months  that  she  has  been  under  the  care 
of  her  present  attendant  she  has  had  emotional  attacks,  periods 
of  mental  depression  and  insomnia,  goes  to  bed,  refuses  food, 
and  if  crossed  becomes  hysterical.  Passed  last  summer  in 
the  country  with  benefit.  In  the  autumn  she  went  to  the 
ofHce  of  her  physician  for  swelling  of  the  face  and  pufhness 
of  the  eyelids,  and  complained  that  the  skin  was  dry  and 
perspiration  deficient.  Nine  months  later  these  symptoms 
persist.  She  denies  special  sensitiveness  to  cold.  Several  ex- 
aminations of  the  urine  have  been  made  with  negative  results. 
The  twenty-four-hour  quantity  is  not  known.  The  pulse  is 
72,  regular;  the  temperature  normal;  the  blood  negative;  the 
tongue  clear.  The  complexion  is  somewhat  waxy;  the  eye- 
lids are  rather  baggy  and  translucent;  the  whole  face  has  a 
puffy  look.  The  skin  —  on  a  warm  day,  June  17  —  is  slightly 
moist.  Visceral  examination  is  negative  except  for  a  mobile 
right  kidney.  No  motor  paralysis;  reflexes  and  sensibility 
normal. 

1 .  What  is  the  significance  of  the  mobile  right  kidney  in  rela- 

tion to  the  other  symptoms  of  this  case?  It  is  insignifi- 
cant and  the  physician  should  on  no  account  mention 
its  presence,  which  may  give  rise  to  great  alarm. 

2.  What  was  the  cause  of  the  hemiplegia  and  aphasia  ?     The 

toxaemia  known  as  eclampsia  seems  to  account  for  them. 
A  small  cerebral  haemorrhage  is  possible. 

3.  What  test  would  make  the  diagnosis  easier?     (See  diag- 

nosis.) 

236 


DISEASES   OF   LYMPHATIC    AND    DUCTLESS    GLANDS.      237 

Diagnosis :  The  age  and  sex,  the  mental  symptoms,  the  dry 
skin  and  puffy,  waxy  face,  with  negative  urine  and  heart, 
strongly  suggest  myxoedema.  The  therapeutic  test  (see  ques- 
tion 3)  confirmed  this  suggestion.  Thyroid  extract  produced 
a  rapid  improvement  and  final  cessation  of  all  the  symptoms. 
The  only  atypical  features  of  the  case  are  the  absence  of  sub- 
normal temperature  and  of  sensitiveness  to  cold.  The  appar- 
ently eclamptic  seizure  in  early  life  is  interesting  in  view  of  the 
possible  connection  between  eclampsia  and  deficient  thyroid 
activity  which  various  writers  have  recently  suggested. 

Prognosis:  If  there  are  no  serious  complications,  the  prog- 
nosis of  myxoedema  under  proper  treatment  should  be  entirely 
favorable.  The  patient,  however,  must  continue  the  treat- 
ment with  occasional  intermissions  for  life.  Any  prolonged 
attempt  to  do  without  medicines  brings  relapse  in  practically 
every  case. 

Treatment :  Since  we  possess  a  specific  for  this  disease,  the 
only  discussable  question  is  as  to  the  preparation  and  the  dose. 
In  my  own  experience  the  tablets  prepared  by  Burroughs  & 
Welcome  have  been  more  reliable  than  those  of  any  American 
firm.  Nevertheless,  excellent  results  are  also  to  be  obtained 
by  the  use  of  any  one  of  the  better-known  American  prepara- 
tions. Our  main  task  is  to  get  in  the  thyroid  in  an  effective 
dose  without  producing  toxic  symptoms.  It  is  well  to  begin 
with  a  two-grain  tablet  once  or  twice  a  day,  and  increase  this 
gradually  until  the  patient  is  taking  5  grains  three  times  a 
day,  or  until  toxic  symptoms  show  themselves.  The  earliest 
toxic  symptom  in  most  cases  is  the  moderate  increase  in  the 
rapidity  of  the  pulse  and  this  should  be  watched  for  by  putting 
the  patient  upon  a  two-hourly  pulse  chart  as  soon  as  the  drug 
is  begun.  If  the  pulse  rises  more  than  ten  beats  without  any 
special  reason,  such  as  bodily  or  mental  excitement,  drugs 
should  be  taken  away  and  begun  later  with  a  smaller  dose  after 
the  pulse  has  resumed  its  normal  rate.  By  a  little  experi- 
menting, a  dose  may  be  found  which  will  keep  the  symptoms 
in  abeyance  without  poisoning  the  patient.  At  this  dose  the 
patient  should  continue  with  occasional  intermission,  perhaps 
one  month  in  three,  or  one  week  in  three,  as  experiment  may 
prove  to  be  wise. 


238  CASE   HISTORIES   IN   MEDICINE. 

Case  88.  Single  lady,  fifty-seven  years  old,  always  more 
or  less  of  a  nervous  invalid,  consults  a  physician  for  palpita- 
tion and  dyspnoea  on  exertion.  The  menopause  occurred 
five  years  ago,  and  since  then  she  has  been  getting  very  stout 
and  disinclined  to  exertion.  She  is  thirsty  and  her  skin  is 
dry  and  perspires  very  little.  Of  late,  the  feet  have  been 
swelling  and  her  face  seems  puffy  all  the  time,  not  especially 
under  the  eyes.  She  is  troubled  a  great  deal  with  headaches, 
worse  at  night,  and  her  hair  has  been  coming  out  of  late.  No 
sore  throat,  but  the  shin  bones  are  tender  and  the  tissues  over 
them  pit  slightly  on  pressure.  The  bowels  are  very  costive, 
appetite  capricious,  sleep  disturbed  by  headache.  Her  mem- 
ory is  very  poor  and  she  takes  little  interest  in  anything. 

Physical  examination:  Heart's  area  cannot  be  marked  out 
on  account  of  the  great  thickness  of  the  fat  layer.  The  apex 
is  not  seen  or  felt;  best  heard  in  sixth  space,  one  inch  outside 
nipple.  Sounds  heard  feebly,  action  irregular.  Pulmonic 
second  sound  accentuated ;  no  murmur.  Lungs  and  abdomen 
negative.  Temperature  97.8°,  pulse  100.  Urine  1018,  acid, 
large  trace  of  albumin,  no  sugar.  Amount  two  quarts.  Sedi- 
ment: hyalin,  granular  casts,  small  diameter,  some  with  cells 
adherent.  Blood:  Red  6,000,000;  white  12,000.  CEdema  of 
ankles.     Hands  and  feet  cold. 

1.  Cause  of  feeble  heart  sounds  in  this  case?     The  thick  fat 

layer. 

2.  What   are   the   common   causes   of   tenderness   over   the 

shins?     CEdema,   periostitis. 

3.  Why  is  the  number  of  red  cells  so  large?     This  number  is 

often  found  in  perfect  health.     Here  it  is  probably  due 
to  weak  circulation  and  peripheral  stasis. 

4.  What  causes  of  chronic  headache  are  common  at  fifty- 

seven?     Uraemia  is  the  only  cause  commonly  found  at 
this  age. 

5.  What  further  tests  are  important  for  diagnosis?     Measure- 

ment of  the  day  and  the  night  urine.     The  effects  of 
thyroid  extract. 

Diagnosis:  (a)  Obesity  and  its  results,  (b)  arteriosclerosis 
with  involution  psychosis,  and  (c)  myxoedema  should  be  con- 
sidered. Neither  of  the  first  two  often  produces  dry  skin  nor 
loss  of  hair.     In  favor  of  myxoedema  are  the  age  and  sex, 


DISEASES   OF  LYMPHATIC   AND   DUCTLESS    GLANDS.     239 

the  cutaneous,  facial,  and  mental  changes,  and  the  sub- 
normal temperature.  The  administration  of  thyroid  extract 
was  followed  by  a  rapid  and  permanent  amelioration  of  all 
the  symptoms  (including  those  referable  to  the  heart  and 
kidney),  and  the  diagnosis  of  myxoedema  was  thus  confirmed. 
Prognosis  and  Treatment :  (see  previous  case). 


240  CASE   HISTORIES    IN   MEDICINE. 

Case  89.  Man,  sixty-six  years  old,  has  had  pain  for  fifteen 
months;  for  the  first  month  it  was  referred  to  the  right 
hip  and  buttock.  Later,  it  was  felt  in  the  small  of  the  back 
and  in  both  scapular  regions;  for  six  months,  pain  has  been 
felt  in  the  other  hip  and  occasionally  in  both  legs. 

For  a  month  he  has  had  considerable  cough,  with  sputum, 
occasionally  blood-streaked.  He  has  always  been  finicky 
about  his  food,  but  complained  of  no  special  digestive  dis- 
turbance, except  loss  of  appetite  and  constipation,  which 
have  been  continuous  and  accompanied  by  loss  of  flesh.  He 
was  previously  very  fat.  For  several  weeks  he  has  been  in 
bed.  Of  late  has  had  several  attacks  of  retention  of  urine, 
needing  catheterization. 

Examination:  Spare,  but  by  no  means  emaciated;  arcus 
senilis  marked.  Heart  negative,  so  also  the  lungs  except  for 
scattered  patches  of  rales  in  both  backs  and  in  the  right 
axilla.  Abdomen  negative.  Knee-jerks  normal;  no  tender- 
ness or  loss  of  sensation.     Spine  straight  and  not  tender. 

Urine  1016,  alkalin,  trace  of  albumin,  considerable  pus 
and  squamous  cells.  Blood:  Red  cells  3,810,000;  white 
cells  17,000;  haemoglobin  55%.  In  the  stained  specimen 
polynuclear  leucocytes  were  abnormally  increased  and  three 
normoblasts  were  seen  during  a  differential  count  of  500  leu- 
cocytes.    Temperature  99°,  pulse  90,  respiration  22. 

1.  What  is  the  significance  of  the  temperature  in  this  case? 

If  it  continues  at  or  below  that  point,  infections  (e.g., 
phthisis  or  sepsis)  are  very  unlikely. 

2.  What  all-important  diagnostic    data    are    here    lacking? 

Pupillary  reactions,  sputum  examination,  the  twenty- 
four-hour  amount  of  urine. 

3.  If   the  knee-jerks  had   been  absent,   what  other  disease 

should  be  considered?     Tabes  dorsalis. 

4.  How   are   the  lung  signs   to  be  interpreted  ?     Localized 

bronchitis  or  oedema. 

5.  What  further  knowledge  do  we  wish  regarding  the  spine  ? 

Is  it  everywhere  normally  flexible  ? 

Diagnosis:  The  spine  was  found  to  be  stiff  in  the  lumbar 
region  and  spondylitis  was  considered.  But  the  loss  of 
appetite,  the  anaemia,  and  the  leucocytosis  pointed  to  some- 
thing less  purely  local  in  its  effects.     Sputum  examination, 


DISEASES   OF   LYMPHATIC   AND   DUCTLESS    GLANDS.     24I 

four  times  repeated,  was  negative  and  practically  excluded 
phthisis.  Abdominal  aneurism  would  account  for  some  of 
the  pains,  but  should  produce  a  palpable  tumor.  The  pains 
are  such  as  would  be  produced  by  pressure  on  the  spinal 
nerve  roots.  Malignant  disease  of  the  prae vertebral  glands 
would  explain  the  pains,  the  anaemia,  and  the  loss  of  appetite. 
Autopsy  confirmed  this  diagnosis  and  showed  in  addition 
numerous  metastases  in  each  lung  —  accounting  for  the 
pulmonary  signs  and  symptoms.  Hypertrophied  prostate 
with  slight  cystitis  explained  the  bladder  symptoms. 

Prognosis :  There  is  no  hope  of  saving  life  since  the  growth 
is  irremovable.  Death  will  probably  occur  within  a  few 
months.     The  treatment  is  essentially  symptomatic. 


242  CASE   HISTORIES   IN   MEDICINE. 

Case  90.  Called  to  see  a  young  girl  of  twenty-one,  single, 
who  is  said  to  have  had,  twelve  hours  before,  a  large  pul- 
monary haemorrhage  —  a  pint  after  a  few  days'  cough. 
Previously  well,  but  nervous;  easily  startled  and  frequently 
troubled  with  food  "  going  the  wrong  way,"  and  causing 
symptoms  of  temporary  spasm  of  the  glottis. 

When  seen,  could  only  speak  in  a  whisper;  throat  exami- 
nation was  impossible  on  account  of  gagging.  Lungs  entirely 
negative,  except  slight  dulness  and  prolonged  expiration  at 
right  apex.  Heart  somewhat  rapid;  systolic  murmur  at  base 
of  the  heart,  loudest  in  pulmonary  area.  At  the  root  of  the 
neck,  in  front,  a  swelling  size  of  a  hen's  egg,  smooth,  soft, 
not  tender.  Abdomen  negative.  Face  very  pale,  lips  less 
so.     Slight  oedema  of  ankles. 

.  Urine  pale,  acid  1018;  albumin,  slighest  possible  trace; 
1%  of  sugar;  amount,  2|  quarts.  Sediment,  mostly  squam- 
ous and  neck  of  bladder  cells.     Few  small  hyalin  casts. 

Blood:   Reds  4,800,000;  whites  10,000;  Hg.60%. 

1.  What  further  information  is  needed  about  the  haemor- 

rhage here?  Did  anyone  see  the  blood  come  up? 
She  may  be  a  malingerer.  Was  the  blood  mixed  with 
air  or  food? 

2.  If  haemorrhage  were  due  in  this  case  to  phthisis,  what 

physical  signs  should  one  expect  to  find  twelve  hours 
after?  None.  The  earliest  physical  signs  usually  ap- 
pear months  later. 

3.  What  else  may  cause  such  haemorrhage?     Gastric  ulcer, 

oesophageal  varices  in  cirrhosis,  leaking  aneurism. 

4.  How  is  the  oedema  of  the  ankles  to  be  accounted  for? 

Probably  anaemia;  possibly  nephritis. 

5.  What  other  causes  of  oedema  can  you  name?     Cardiac 

weakness,  obesity,  neuritis,  thrombosis,  varicose  veins, 
or  other  local  causes  of  venous  obstruction. 

6.  Significance  of  the  lung  signs  in  this  case?     They  are 

within  physiological  limits. 

7.  By  what   further  methods  of  examination   could   their 

significance  be  more  definitely  determined?  Sputum 
examination  after  administration  of  KI.  Tempera- 
ture records,  tuberculin  reaction. 

8.  Name  three  causes  of  systolic  murmurs  loudest  in  the 

pulmonary  area.  "  Functional  "  changes,  aneurism, 
pulmonary  stenosis. 


DISEASES   OF   LYMPHATIC   AND   DUCTLESS   GLANDS.     243 

9.  Can  the  neck  tumor  be  connected  in  any  way  with  the 
glottic  spasm?  Why  or  why  not?  No,  because  the 
tumor  is  too  small  and  too  far  from  the  glottis. 

10.  From  the  data  given  about  the  blood,  what  should  one 

expect  to  find  in  the  stained  blood  film?  Small,  pale 
red  cells,  not  otherwise  abnormal.  Normal  leucocyte 
percentages. 

11.  What  conclusions  should  be  drawn  from  the  urine  in  this 

case?  None  that  are  definite.  The  causes  of  the 
albuminuria  and  of  the  glycosuria  should  be  sought. 


Diagnosis :  Goiter  and  tachycardia  suggest  Graves'  disease. 
We  do  not  know  whether  or  not  the  eyes  protruded  or  whether 
there  was  tremor.  Pulmonary  bleedings,  glycosuria,  albu- 
minuria, and  anaemia  have  repeatedly  occurred  without  known 
cause  in  Graves'  disease.  Phthisis  and  malingering  must  be 
excluded  by  the  methods  suggested  under  questions  one  and 
seven.  Aneurism  causes  aphonia  and  (if  it  leaks)  bleeding. 
There  are  none  of  the  other  physical  signs  of  aneurism  in  this 
case,  but  an  X-ray  may  be  needed  to  exclude  it.  The  glottic 
spasm  and  aphonia  occur  in  many  neuroses  and  are  charac- 
teristic of  none.  Exophthalmic  goiter  turned  out  the  true 
diagnosis,  other  alternatives  being  excluded. 

Prognosis:  A  great  majority  of  cases  tend  to  spontaneous 
improvement  which  may  be  prolonged  for  weeks  and  months 
and  may  be  of  any  degree  from  a  slight  amelioration  to  almost 
total  recovery.  This  fact  is  of  the  greatest  importance  in 
estimating  the  effects  of  any  particular  plan  of  treatment. 
The  great  majority  of  cases  run  a  chronic  course  with  periods 
of  improvement  such  as  have  already  been  suggested.  Occa- 
sionally malignant  types  of  the  disease  are  met  with  and 
patients  succumb  either  to  cardiac  failure  with  dilatation, 
or  to  toxic  symptoms  such  as  diarrhoea,  vomiting,  fever, 
insomnia,  and  profuse  sweating.  It  should  be  remembered 
that  many  cases  are  aggravated  by  the  conditions  following 
childbirth.  During  the  pregnancy  the  symptoms  may  be 
greatly  improved. 

In  any  given  case  prognosis  is  worse  if  the  patient  is  ema- 
ciated, the  pulse  is  persistently  above  120,  if  diarrhoea,  fever, 
sweating,  or  insomnia  are  present. 


244  CASE   HISTORIES   IN   MEDICINE. 

Treatment:  On  the  whole  the  most  effective  method  of 
attacking  the  disease  is  by  surgery.  Whenever  the  symptoms 
are  enough  to  disable  a  patient  from  her  ordinary  occupations, 
operation  should  be  advised,  provided  one  can  get  the  services 
of  a  surgeon  who  has  had  considerable  experience  and  shows 
considerable  proficiency  in  dealing  with  this  particular  disease. 
The  cases  in  which  operation  is  inadvisable  are  those  at  the 
two  extremes,  the  mildest  and  the  severest;  however,  even 
the  severest  case  may  sometimes  be  sufficiently  ameliorated 
by  some  of  the  milder  methods  presently  to  be  mentioned  so 
that  operation  becomes  safe  and  practicable,  especially  if  the 
psychic  elements  of  the  case  are  not  lost  sight  of. 

As  regards  nonsurgical  treatment,  it  is  clear  in  the  first 
place  that  general  hygiene  such  as  we  provide  for  the  tuber- 
culous or  the  epileptic  is  of  very  distinct  value.  In  this 
regime  the  elements  of  improvement  are  rest  in  the  open  air, 
hypernutrition  to  combat  the  tendency  to  emaciation,  free- 
dom from  all  emotional  and  physical  strain.  The  problem 
of  occupying  a  patient  who  cannot  take  part  in  any  of  the 
ordinary  activities  of  life  is  here,  as  in  tuberculosis,  a  difficult 
one,  yet  it  is  important  that  something  should  be  devised 
whereby  the  patient  may  not  fret  and  worry  more  than  is 
inevitable  in  so  tedious  and  disappointing  a  disease. 

As  regards  medicinal  treatment  I  have  seen  little  that  con- 
vinces me  of  its  value.  In  my  hands  the  Rogers-Beebe  serum 
has  not  produced  any  results  striking  enough  to  convince  one 
of  its  value;  that  is,  the  percentage  of  definite  improvement 
does  not  seem  to  me  much  greater  than  is  to  be  expected  under 
hygienic  management  alone.  The  neutral  bromid  of  quinin 
so  strongly  recommended  by  Forscheimer  and  by  J.  M, 
Jackson  has,  I  think,  some  effect  in  diminishing  the  nervous- 
ness and  excitability  of  the  patient,  but  it  is  by  no  means  a 
brilliant  remedy.  Other  drugs  have  been  quite  powerless  in 
my  hands.  As  a  rule  I  give  the  neutral  bromid  of  quinin 
in  doses  of  5  grains  three  times  a  day,  diminishing  the  dose  if 
the  ears  ring  disagreeably. 

The  use  of  X-ray  exposures  over  the  thyroid  gland  has  been 
recommended  by  the  Mayos  as  a  preliminary  and  auxiliary 
treatment  in  connection  with  operative  interference.     G.  W. 


DISEASES   OF   LYMPHATIC   AND   DUCTLESS   GLANDS.      245 

Crile  has  laid  stress  upon  the  importance  of  eHminating  so  far 
as  possible  the  psychic  factors  in  connection  with  operative 
treatment.  He  believes  that  terror  excited  by  the  antici- 
pations of  operation  and  of  anaesthesia  has  much  to  do  with 
the  high  operative  mortality  of  some  surgeons,  and  conse- 
quently he  has  worked  out  a  technique  whereby  the  patient 
scarcely  suspects  that  any  operation  is  to  be  performed  until 
it  is  over. 

Even  in  the  successful  cases  a  regime  similar  to  that  above 
suggested  has  to  be  carried  out  more  or  less  strictly  after 
operation. 

To  discuss  the  various  types  of  operation  for  hyperthyroid- 
ism performed  by  different  surgeons  is  beyond  the  scope  of 
this  book. 


246  CASE   HISTORIES   IN   MEDICINE. 

Case  91.  A  boy,  fourteen  years  old,  of  gouty  family  history, 
complains  for  a  year  of  frontal  headache,  not  very  severe 
but  persistent  and  wearing.  Appetite  excellent,  but  diges- 
tion not  as  good  as  it  has  been.  Has  grown  suddenly  very 
irritable,  having  been  previously  sweet-tempered.  He  has 
lost  flesh  during  the  year  and  seems  listless  and  weak.  Sleeps 
well.  Bowels  somewhat  costive.  Getting  pale.  Heart, 
lungs,  and  abdomen  negative.  Knee-jerks  not  easily  ob- 
tained, but  gait  shows  only  weakness.  Urine  normal  color, 
acid,  1028,  no  albumin.  Sediment  negative.  Temperature 
98'^,  pulse  96.     No  oedema.     Blood  negative. 

1.  What    possible    causes    for    the    change    in    disposition? 

Masturbation,  psychosis  of  puberty,  brain  tumor,  dia- 
betes. 

2.  Causes    of     frontal    headache    commonest    at    fourteen? 

Eyestrain,  adenoids,  frontal  sinus  disease,  malaria, 
pubescence. 

3.  Significance  of  pallor  both  in  general  and  in  this  case? 

Pallor  may  mean  anaemia,  but  often  does  not.  Deficient 
skin  circulation,  congenital  or  acquired  (stokers,  resi- 
dents in  the  tropics),  is  a  more  frequent  cause.  Many 
consumptives  and  many  neurasthenics  are  pale,  but 
few  are  ansemic.  Nausea  and  faintness  produce  local 
anaemia,  and  of  course  without  blood  change.  No  diag- 
nosis of  anaemia  is  justified  until  the  physician  has  seen 
the  color  of  a  drop  of  blood  on  filter  paper  (Talquist 
scale)  or  on  a  handkerchief.  In  this  case  no  anaemia  was 
present. 

Diagnosis :  The  careful  student  of  this  case  will  notice  first 
of  all  the  loss  of  flesh  despite  good  appetite.  Emaciation  with 
persistent  headache  and  diminished  knee-jerks,  are  the  obvi- 
ous physical  signs.  Eyestrain,  adenoids,  malaria,  mastur- 
bation were  easily  excluded  by  examination  and  watching. 
Further  questions  revealed  the  fact  that  micturition  was 
frequent  and  copious.  This,  with  the  loss  of  flesh  despite 
good  appetite,  suggested  diabetes,  and  the  urine  was  found 
on  examination  to  contain  sugar  —  a  point  omitted  in  the 
examination  of  the  attending  physician  and  therefore  omitted 
in  the  above  description  of  the  case.  As  the  glycosuria 
proved  persistent,  the  diagnosis  of  diabetes  mellitus  was 
made.     No  acetone  or  diacetic  acid  was  found  in  the  urine  at 


DISEASES   OF  LYMPHATIC   AND  DUCTLESS  GLANDS.     247 

this  time.  The  sugar  was  5% ;  urine,  three  quarts  in  twenty- 
four  hours. 

Prognosis:  As  regards  the  outlook  in  diabetes,  we  may 
divide  cases  into  two  groups:  the  fat,  old  patients  in  whom 
the  disease  may  be  mild  or  almost  trifling  in  severity ;  and  the 
young,  thin  patients  in  whom  it  is  as  a  rule  fatal  within  a 
few  years.  Patients  occupying  intermediate  positions  be- 
tween these  two  groups  have  a  correspondingly  intermediate 
prognosis.  I  have  seen  stout,  elderly  patients  who  got  along 
without  any  decided  inconvenience  for  ten  years  or  more, 
although  they  did  not  modify  their  ordinary  diet  in  the  least. 
Probably  cases  so  mild  as  this  are  rare,  yet  there  are  many 
in  this  group  whose  symptoms  are  very  slight  if  they  will  sub- 
mit to  short  periods  of  treatment  once  or  twice. a  year. 

Under  these  conditions  patients  may  live  for  many  years 
and  often  die  of  some  other  malady. 

Among  the  young,  thin  cases  the  longest  that  I  have  ever 
known  occurred  in  a  young  man  whose  first  symptoms 
appeared  at  the  age  of  twenty,  and  who  lived  and  worked 
for  eleven  years  thereafter,  being  most  of  that  time  upon 
strict  diabetic  diet.  As  a  rule  one  cannot  prolong  life  beyond 
four  or  five  years  in  young,  thin  patients. 

Acute  cases  occur  especially  in  children  and  young  adults, 
and  may  prove  fatal  within  a  few  months. 

An  important  factor  in  prognosis  is  the  patient's  ability 
and  willingness  to  submit  to  proper  treatment.  Many  are 
able  but  not  willing;  some  are  willing  but  not  able,  owing  to 
poverty  or  other  conditions.  The  amount  of  determination 
necessary  to  stick  to  a  strict  diabetic  diet  through  months 
and  years  is  possessed  by  but  very  few  people,  hence  very 
few  patients  are  successfully  treated  except  in  sanatoria 
where  their  diet  can  be  rigidly  controlled  without  regard 
to  their  wishes. 

Cases  benefited  by  antisyphilitic  treatment  are  said  to 
give  a  better  prognosis  than  any  others,  but  these  are  exceed- 
ingly rare.  I  have  never  seen  one.  In  many  cases  the 
prognosis  is  rendered  more  serious  owing  to  the  presence  of 
a  complicating  disease  such  as  arte^osclerosis,  nephritis,  or 
valvular  heart  disease. 


248  CASE   HISTORIES   IN   MEDICINE. 

Treatment:  In  the  treatment  of  diabetes  the  physician 
should  be  constantly  guided  by  three  sets  of  data.  He  must 
watch  the  urine,  not  only  for  the  presence  and  the  amount 
of  sugar,  but  for  the  presence  and  amount  of  organic  acids, 
and  he  must  always  keep  track  of  the  patient's  weight.  By 
reference  to  these  three  factors,  sugar,  acids,  and  weight,  we 
attempt  to  steer  the  best  course  we  can  in  the  management 
of  the  disease.  It  is  not  enough  to  free  the  urine  from 
sugar,  we  must  free  it  from  sugar  without  making  the  patient 
lose  weight  after  the  first  week  or  two,  and  without  poison- 
ing his  system  with  organic  acid. 

To  accomplish  these  ends  simultaneously  it  is  essential  to 
remember  that  what  we  add  to  the  ordinary  diet  is  as  impor- 
tant as  what  we  take  away  from  it.  To  increase  the  fats  in 
the  foods  is  as  important  as  to  cut  off  the  carbohydrates; 
otherwise  we  starve  our  patient. 

At  the  beginning  of  treatment  the  carbohydrates  should 
be  gradually  reduced  so  that  in  the  course  of  a  week  they 
are  practically  excluded.  During  this  week  the  patient 
should  be  given  bicarbonate  of  soda  in  doses  sufficient  to 
keep  the  urine  neutral.  The  amount  necessary  to  accom- 
plish this  varies  greatly  in  different  cases.  One  should  begin 
with  a  teaspoonful  of  bicarbonate  of  soda  every  two  hours, 
and  then  increase  or  diminish  as  may  be  necessary  to  keep 
the  urine  neutral.  Besides  the  proteid  foods  such  as  meat, 
fish,  and  eggs  in  their  various  forms,  we  should  see  that  the 
patient  takes  an  increased  amount  of  cream,  butter,  cheese, 
fat  meat  such  as  bacon,  and  olive  oil  in  the  form  of  salad. 
The  amount  of  these  fats  should  be  such  as  will  maintain  or 
increase  the  patient's  weight.  If  this  Is  carefully  watched 
it  Is  not  necessary  to  calculate  the  calory  values  of  the 
food. 

Diabetic  breads  should  be  excluded  altogether.  There  are 
none  upon  the  market  which  can  be  relied  upon.  Milk  is  not 
to  be  allowed  while  the  patient  is  on  strict  diet.  It  is  one  of 
the  foods  to  be  permitted  as  soon  as  the  diabetics  begin  to 
relax  their  regimen.  Saccharin  may  be  used  in  unlimited 
amounts  to  sweeten  tea,  coffee,  jellies,  and  anything  else  in 
which  the  patient  desires  a  sweet  taste. 


DISEASES   OF   LYMPHATIC   AND    DUCTLESS    GLANDS.      249 

A  strict  diet  should  be  continued  for  several  months,  pro- 
vided the  patient  holds  his  weight  or  gains,  and  does  not  show 
a  dangerous  amount  of  organic  acid  in  the  urine.  At  the  end 
of  that  time  one  may  gradually  relax  the  diet  provided  the 
urine  has  become  sugar-free.  Bread  is  the  substance  which 
the  patient  most  craves,  and  he  may  be  given  at  first  a  slice 
a  day,  later  two  or  three  slices,  provided  he  can  assimilate 
it  without  passing  sugar.  At  any  time  it  may  be  neces- 
sary to  add  carbohydrates  to  the  diet  if  the  patient  loses 
weight  or  shows  a  large  quantity  of  organic  acid  in  the 
urine. 

If,  on  the  other  hand,  despite  the  exclusion  of  carbo- 
hydrates, we  cannot  free  the  urine  from  sugar,  the  following 
manoeuvres  may  be  tried,  (i)  We  may  cut  down  the  amount 
of  proteid  food  by  one-third  or  two-fifths,  allowing  the  patient 
not  more  than  50  or  60  grams  of  proteid  a  day.  This  sometimes 
results  in  freeing  the  urine  from  sugar  when  strict  exclusion 
of  carbohydrates  has  not  been  sufficient  to  produce  this  result. 
(2)  We  may  prescribe  what  the  Germans  call  a  "  green  day," 
—  that  is,  we  may  exclude  for  twenty-four  hours  all  carbo- 
hydrates and  all  proteid  food,  allowing  only  green  vegetables 
and  fats.  (3)  If  this  measure  is  not  sufficient  we  may  try 
twenty-four  hours  of  starvation,  allowing  only  clear  soups 
and  water. 

I  remember  one  case  in  which  strict  diet  had  been  wholly 
ineffective  in  freeing  the  urine  from  sugar,  yet  in  which  the 
urine  after  a  period  of  thirty-six  hours'  starvation  remained 
sugar-free  for  several  months  on  a  diet  free  from  carbohydrates. 

There  are  patients  who  can  bear  some  one  form  of  starch 
far  better  than  others.  Some  have  a  remarkable  tolerance 
for  oatmeal,  others  for  milk-sugar,  for  Isevulose,  or  for  potato 
starch.  One  should  experiment  in  each  case  with  these  car- 
bohydrates, to  see  whether  the  patient  can  get  the  benefit  of 
them  without  passing  sugar. 

In  the  milder  cases  a  month  of  strict  diet  once  or  twice  a 
year  may  suffice  to  keep  the  patient  in  good  condition  and 
nearly  or  quite  sugar- free.  In  the  severer  cases  one  must 
persist  with  diet  practically  all  the  time* 

Aside  from  diet  there  is  nothing  to  be  said  as  to  treatment 


250  CASE   HISTORIES   IN   MEDICINE. 

except  that  exercise  in  moderation,  sleeping  in  the  open  air, 
unusual  attention  to  cleanliness  of  the  skin,  and  the  use  of 
such  a  regime  as  will  keep  up  the  patient's  courage  are  valuable 
adjuvants.  Drugs  have  in  my  experience  no  power  over  the 
disease.     Opium  does  fully  as  much  harm  as  good. 


DISEASES   OF   LYMPHATIC   AND   DUCTLESS   GLANDS.      25 1 

Case  92,  A  widow  of  fifty-three  noticed  five  years  ago  a 
swelling  of  the  left  leg  extending  from  the  hip  to  the  toes  and 
lasting  about  six  months.  After  that  she  had  no  symptoms 
of  any  kind  until  a  year  ago  when  a  bunch  appeared  in  the 
left  groin.  There  has  been  slight  if  any  increase  in  its  size 
since  that  time  and  she  has  noticed  nothing  else  wrong  until 
five  weeks  ago  when  she  began  to  have  pain  in  the  left  hip, 
in  the  left  buttock,  and  down  the  back  of  the  leg.  This  pain 
has  never  been  severe  and  has  never  prevented  sleep.  Indeed 
she  scarcely  notices  it  except  when  she  walks.  This  pain  has 
been  accompanied,  however,  by  a  moderate  degree  of  swelling 
of  the  whole  leg.  In  other  respects  she  feels  perfectly  well. 
She  has  a  good  appetite  and  has  lost  no  weight. 

Physical  examination  is  negative  except  for  a  moderate 
swelling  of  the  whole  left  leg  and  a  hard,  irregular  mass  the 
size  of  half  a  lemon  in  the  left  groin.  Nothing  abnormal  is 
felt  by  vagina.     The  haemoglobin  is  75%,  urine  normal. 

I .  What  are  the  common  causes  foi"  swelling  of  the  whole  leg? 
Phlebitis;  inflammatory  oedema  accompanying  a  septic 
wound  with  or  without  a  demonstrable  lymphangitis; 
elephantiasis;  passive  congestion  due  to  the  pressure  of 
tumors  in  or  about  the  pelvis. 

Diagnosis:  We  have  no  evidence  of  phlebitis,  no  tender, 
indurated  cord  over  the  site  of  the  pain,  no  fever  or  leuco- 
cytosis.  There  is  no  sign  of  lymphangitis  or  acute  sepsis. 
Elephantiasis  would  not  account  for  the  mass  in  the  groin  nor 
for  the  sciatic  pain,  although  elephantiasis  may  be  accom- 
panied by  some  subcutaneous  oedema  such  as  is  here  present. 
It  is  natural,  therefore,  to  assume  that  the  mass  in  the  left 
groin  is  connected  with  some  deeper  growth  which  produces 
the  pain  and  oedema  through  pressure  on  nerves  and  veins. 
The  only  thing  to  give  us  pause  is  the  history  of  an  attack 
five  years  ago  apparently  of  similar  nature.  Is  it  possible 
that  malignant  disease  can  have  existed  so  long  and  produced 
no  symptoms  during  intervals  of  nearly  four  years?  We 
cannot  deny  the  possibility,  and  the  diagnosis  of  neoplasm 
with  pressure  symptoms  seems  therefore  the  most  reason- 
able. Only  by  the  excision  of  a  portion  of  the  glandular  mass 
can  we  arrive  at  any  further  certainty. 


252  CASE   HISTORIES   IN   MEDICINE. 

Prognosis:  Since  there  is  no  considerable  possibility  of 
extirpating  a  growth  such  as  may  be  assumed  to  be  here 
present,  deep  in  the  pelvis,  we  can  offer  no  hope  of  recovery. 
Life  will  probably  not  be  many  months  prolonged. 

Treatment  must  be  purely  palliative. 


DISEASES   OF   LYMPHATIC    AND   DUCTLESS   GLANDS.      253 

Case  93.  A  plumber  of  forty,  of  good  family  and  pre- 
vious history  and  good  habits,  had  clap  many  years  ago  with 
good  recovery. 

One  year  ago  he  had  an  obstinate  cough  with  expectora- 
tion (not  examined)  and  a  "  patch  "  in  his  right  lower  front 
chest.  He  went  to  Florida  and  recovered  entirely.  About 
two  months  ago  he  noticed  swelling  of  the  face  and  neck, 
especially  in  the  morning,  and  had  to  enlarge  his  collars. 
Stooping  caused  headache,  a  slight  choking  sensation,  and 
swelling  of  the  veins  of  his  face  and  neck.  After  some 
weeks  he  had  fever,  malaise,  and  swollen  tender  glands  ( ?) 
in  the  neck,  especially  on  the  left  side.  In  the  course  of  a 
week  he  was  so  much  better  that  he  resumed  work.  Re- 
cently the  swelling  of  the  face  and  neck  have  returned  and 
are  more  marked  in  the  morning.  The  left  arm  has  also 
swollen,  without  pain  or  tenderness.  He  has  had  several 
nosebleeds,  with  relief  to  his  head.  Yesterday  his  temper- 
ature was  101.4°,  to-day  99.6°.  Pulse  80,  regular.  The 
appetite,  digestion,  bowels,  sleep,  and  respiration  are  normal. 
The  eyelids  have  been  puffy,  but  are  not  so  now.  The  face, 
neck,  and  upper  part  of  the  thorax  are  swollen  and  hyperaemic. 
The  veins  of  the  arms  and  their  valves  are  very  distinct, 
especially  on  the  left  side,  and  are  markedly  dilated  in  the 
left  lower  axillary  region  and  along  the  right  diaphragmatic 
attachment.  Visceral  examination,  the  blood,  and  the  urine 
are  negative,  also  the  throat.  The  voice  is  clear.  No  glands 
in  either  axilla  or  groin. 

1.  What  are   the   possible   causes  of  swelling  of  one  arm? 

Venous  thrombosis  or  pressure  on  a  venous  trunk 
between  the  arm  and  the  heart;  inflammatory  exuda- 
tion (sepsis) ;  arterial  thrombosis.  Occasionally  drop- 
sical oedema  may  settle  in  one  arm  if  the  patient  has 
been  lying  long  on  one  side. 

2.  What  are  the  common   causes  of  swelling  of  the  face? 

Nephritis,  cardiac  disease,  inflammatory  oedema  (as  in 
erysipelas),  angioneurotic  oedema.  In  the  early  morn- 
ing many  persons  have  swelling  of  the  face  off  and  on 
without  known  cause  or  sequelae. 

3.  What  can  be  inferred  from  the  increase  of  the  swelling 

in    the    early    morning?     All    types    of    facial    oedema 


254  CASE   HISTORIES   IN   MEDICINE. 

(whether  of  known  or  unknown  origin)  are  apt  to  be 
more  marked  in  the  morning.  Hence  this  change  has 
no  diagnostic  value. 

Diagnosis:  CEdema  and  hyperaemia  of  face,  neck,  upper 
thorax,  and  left  arm,  with  dilated  veins  in  these  areas  and 
lumps  in  the  neck  (later  disappearing),  point  to  mediastinal 
pressure  on  venous  trunks.  There  are  no  signs  of  aneurism. 
New  growth  is  the  only  alternative.  The  thymus  is  a  possi- 
ble site  of  origin  for  the  tumor.  The  other  facts  in  the  case 
are  consistent  with  this  diagnosis  —  which  was  confirmed  at 
autopsy  —  cancer  of  the  thymus  with  metastases. 

Prognosis :  The  outlook  is  hopeless  and  only  a  few  months 
of  life  can  be  expected. 

Treatment:  Since  it  is  presumably  impossible  to  excise  the 
growth,  we  can  do  nothing  except  carry  out  a  purely  palli- 
ative and  symptomatic  regime  including  the  use  of  X-ray 
exposures. 


CHAPTER  VIII. 
DISEASES   OF   UNKNOWN   ORIGIN. 

Case  94.  A  medical  student  of  twenty-five  has  been 
troubled  with  his  joints  for  ten  years.  Attacks  of  pain  and 
stiffness  lay  him  up  whenever  he  is  subjected  to  any  strain, 
mental  or  physical.  He  has  had  little  or  no  fever,  he  thinks, 
in  any  of  the  attacks,  but  the  pain  and  swelling  have  been 
considerable.  He  has,  as  a  rule,  one  or  two  bad  attacks  each 
year,  with  a  week  or  two  in  bed. 

The  knees,  ankles,  hips,  hands,  wrists,  and  elbows  have 
been  affected,  and  in  every  case  some  stiffness  and  more  or 
less  swelling  have  remained  after  the  pain  left.  Both  sides 
are  affected  nearly  alike. 

Of  late  years  the  attacks  have  grown  less  severe,  especially 
since  his  family  has  grown  more  prosperous  and  more  harmo- 
nious.    He  is  now  able  to  attend  to  most  of  his  medical  work. 

Examination  shows  no  motion  in  the  left  wrist  and  very 
little  in  either  ring  finger.  The  range  of  motion  in  the  knees 
and  elbows  is  also  considerably  limited.  The  fingers  are 
cold,  mottled,  and  damp.  Some  of  the  finger  joints  and  both 
wrists  are  doughy  and  semifluctuant.  There  is  no  evidence 
of  bony  enlargement  anywhere. 

The  heart  and  internal  viscera  are  negative,  but  the  boy 
is  pale  and  rather  thin.     Blood  and  urine  normal. 

1.  Types    and    causes    of    arthritis?      Infectious    (including 

acute  "  rheumatism  "),  atrophic,  hypertrophic,-  gouty, 
neuropathic,  haemophilic. 

2.  What    varieties    of    arthritis    are    often    associated    with 

cardiac  disease?  Only  the  infectious  types:  e.g.,  "  rheu- 
matic," septic,  gonorrhoeal,  scarlatinal,  pneumococcal. 
Tuberculous  and  syphilitic  infections  of.  joints  are  rarely 
associated  with  endocarditis. 

3.  What  important  data  are  not  mentioned   in  the  above 

description?  X-ray  examination,  data  regarding  gon- 
orrhoea and  regarding  muscular  atrophy. 

25s 


256  CASE   HISTORIES    IN   MEDICINE. 

Diagnosis:  X-ray  examination  showed  notable  atrophy 
of  the  articular  ends  of  the  bones.  There  was  marked  mus- 
cular atrophy.  No  history  of  gonorrhoea  or  of  any  other 
infection.  The  absence  of  any  known  infection,  the  long 
progressive  course  in  a  young  person,  the  symmetrical  in- 
volvement of  joints,  the  vasomotor  signs,  the  absence  of 
marked  fever,  and  the  X-ray  evidence  all  point  to  atrophic 
arthritis  and  serve  (with  the  negative  condition  of  the  vis- 
cera, blood,  and  urine)  to  exclude  other  varieties. 

Prognosis:  The  majority  of  cases  slowly  progress,  joint 
after  joint  being  attacked,  the  amount  of  stiffness  steadily 
increasing.  As  a  rule  pain  is  most  severe  in  the  early  years 
of  the  disease,  but  any  strain  or  jar  may  produce  acute 
suffering  in  the  affected  joints.  On  the  other  hand,  it  is 
always  possible  for  the  disease  to  cease  its  activity  and 
progress  no  farther.  The  crippled  joints  never  recover,  but 
if  their  number  is  not  large,  the  patient  may  get  used  to  them 
and  get  along  very  fairly  well  in  spite  of  his  handicap. 

The  worst  cases  are  those  coming  on  in  early  life  in  patients 
already  debilitated  and  scantily  provided  with  courage  and 
interest  in  the  world  around  them. 

Treatment:  The  best  results  are  obtained  by  abandoning 
all  attempts  at  local  treatment  and  prescribing  a  regimen 
practically  identical  with  that  used  in  tuberculosis,  in  order 
that  everything  may  be  done  to  increase  the  patient's  re- 
sistance to  the  inroads  of  the  unknown  cause  of  the  disease. 
In  the  acute  attacks  when  the  joints  are  painful  and  fever 
is  present,  the  measures  used  in  other  acute  joint  troubles 
are  of  some  value,  i.e.,  complete  rest,  friction,  local  applica- 
tions of  heat,  and  aspirin  or  salicylate  of  sodium  internally. 
At  other  times  the  patient  should  endeavor  to  live  his  life 
despite  the  limitations  enforced  by  his  joint  troubles.  Any- 
thing that  hampers  and  depresses  the  patient  will  make  the 
joints  worse.  He  must  occupy  himself  and  keep  busy.  I 
have  one  friend,  a  physician,  who  despite  a  very  advanced 
and  painful  stage  of  the  disease,  has  successfully  practiced 
medicine  for  the  last  seven  years.  I  am  sure  that  his  suffer- 
ings have  been  less  because  he  has  forced  himself  to  work. 

When  the  disease  is  especially  troublesome  in  a  single 
joint  and  when  anchylosis  has  occurred  in  that  joint,  some 
relief  may  be  obtained  by  a  surgical  excision. 


DISEASES  OF   UNKNOWN   ORIGIN.  257 

Case  95.  Mrs.  M.,  thirty  years  old,  is  seen  in  consulta- 
tion October  10,  1905.  She  had  her  first  baby  five  months 
ago,  and  following  delivery  a  severe  albuminuria  (j  to  |%) 
without  any  urinary  abnormality  in  amount,  specific  gravity, 
or  color.  The  attending  physician  found  very  scanty  hyalin 
casts,  otherwise  nothing  pathological  in  the  sediment.  With 
rest  in  bed  and  exclusive  milk  diet  the  urine  became  normal 
in  the  course  of  five  weeks,  but  after  a  return  to  ordinary 
diet  albumin  reappeared  and  she  was  again  on  milk  diet  for  a 
period  of  seven  weeks.  In  neither  of  these  attacks  was  there 
any  oedema  or  any  ursemic  manifestation. 

While  convalescent  from  this  trouble  (but  after  solid  food 
had  been  begun)  the  patient  began,  eight  days  ago,  to  have 
bleeding  from  the  gums,  from  the  rectum,  and  subcutane- 
ously.  The  spots  under  the  skin  were  of  various  sizes,  per- 
haps twenty  in  all,  and  occurred  mostly  on  the  arms  and 
legs.  The  bleeding  ceased  in  two  days;  it  was  not  accom- 
panied by  subjective  symptoms  of  any  kind,  and  the  patient 
now  feels  quite  well  though  rather  weak.     She  is  still  in  bed. 

She  looks  the  picture  of  health.  Her  color  is  bright,  there 
is  no  emaciation.  There  is  a  loud,  harsh,  systolic  murmur 
audible  all  over  the  precordia,  but  best  heard  in  the  third 
left  interspace  near  the  sternum.  The  pulmonic  second  sound 
is  slightly  louder  than  the  aortic.  The  heart  is  not  enlarged. 
The  other  viscera  show  nothing  abnormal.  The  gums  are 
entirely  normal,  as  they  have  been  throughout.  A  few 
"  black  and  blue  "  spots  still  remain  upon  the  extremities. 
The  urine  is  2|  pints  in  twenty-four  hours.  Specific  gravity 
1030,  no  albumin,  no  sugar. 

Blood:  Red  cells  3,552,000;  white  cells  8000.  Haemoglobin 
55%-  The  stained  film  shows  achromia  and  moderate  poikil- 
ocytosis,  but  is  otherwise  normal.  The  temperature  ranges 
between  97°  and  99.4°.  Twice  in  the  last  fortnight  it  has 
reached  100°. 

I.  Causes  of  albuminuria?  Passive  congestion  of  the  kid- 
ney, infectious  fevers,  the  "  irritation  "  of  bile  or  sugar 
in  the  urine,  nephritis,  renal  arteriosclerosis,  haematuria, 
and  pyuria  from  any  cause,  the  intermixture  of  vaginal 
discharges.  In  many  cases  (orthostatic,  adolescent)  no 
cause  can  be  found. 


258  CASE   HISTORIES   IN   MEDICINE. 

2.  Causes  of  subcutaneous  haemorrhage?      Traumatism,  in- 

fections (such  as  meningitis,  typhus,  sepsis,  and  the  ex- 
anthemata), toxic,  cachectic,  scurvy,  arthritic  purpura, 
unknown  causes  ("  simple  "  purpura,  purpura  haemor- 
rhagica) . 

3.  Causes  of  anaemia  such  as  is  here  described?     Haemorrhage, 

malaria,  typhoid  (rarely),  malignant  disease,  dysen- 
tery, chronic  suppurations,  nephritis,  cirrhosis,  chlo- 
rosis, intestinal  parasites. 

Diagnosis:  Puerperal  nephritis  and  the  long  ensuing  milk 
diet  account  for  the  anaemia.  The  heart  murmur  has  the 
characteristics  of  a  "  hemic  "  or  "  functional  "  affair.  The 
purpura  is  probably  of  the  "  simple  "  type,  i.e.,  it  is  not  severe 
or  dependent  on  any  known  cause.  The  fever  is  easily  ac- 
counted for  by  the  anaemia  and  confinement  to  bed.  The 
harshness  of  the  cardiac  murmur  might  suggest  fears  that 
septic  endocarditis  was  present  and  responsible  for  the  fever  and 
haemorrhages,  but  the  position  of  the  murmur,  the  absence  of 
chills,  leucocytosls,  or  marked  pyrexia  make  this  fear  groundless. 

Prognosis:  The  outlook  depends  almost  wholly  upon  the 
cause  of  the  anaemia,  very  little  upon  its  degree.  When  the 
cause  has  ceased  to  act,  or  can  be  removed  as  in  posthaemor- 
rhagic  or  postmalarial  anaemia,  recovery  is  almost  always 
prompt  and  permanent.  On  the  other  hand,  when  a  chronic 
nephritis,  a  neoplasm,  or  a  cirrhotic  liver  is  in  the  background, 
we  can  have  little  hope  of  permanent  improvement  of  anae- 
mia as  the  result  of  any  treatment  whatsoever. 

Probably  the  best  prognosis  of  all  the  types  of  secondary 
anaemia  should  be  given  in  the  type  ordinarily  known  as 
chlorosis,  which  in  fact  is  a  secondary  anaemia  of  unknown 
cause.  Aside  from  this  disease  we  may  say  that  the  prog- 
nosis of  a  secondary  anaemia  is  wholly  the  prognosis  of  what- 
ever disease  underlies  It.  If  that  disease  is  curable,  the 
anaemia  will  take  care  of  itself.  If  it  is  incurable,  we  cannot 
help  the  anaemia.  Relapse  does  not  occur  in  any  of  the  types 
of  secondary  anaemia  except  those  In  which  the  cause  itself 
recurs,  as,  for  example,  the  posthaemorrhagic  anaemias  due 
to  haemophilia  or  haemorrhage  from  gastric  ulcer.  Chlorosis 
shows  a  certain  tendency  to  relapse  in  all  cases,  presumably 
because  its  unknown  cause  becomes  again  active. 


DISEASES   OF   UNKNOWN   ORIGIN.  259 

Treatment:  Obviously  we  must  try  to  remove  the  cause 
whenever  that  is  possible.  Syphilitic  or  malarial  infection, 
if  combatted  by  the  ordinary  methods,  soon  cease  to  be  com- 
plicated by  any  considerable  degree  of  anaemia,  provided 
nutrition  is  good.  In  other  types  of  disease,  when  the  cause 
cannot  be  removed,  the  most  that  we  can  do  in  combatting 
the  anaemia  is  to  nourish  the  patient.  Iron  and  arsenic  are 
rarely  of  value  in  these  cases.  I  have  never  seen  any  im- 
provement following  the  use  of  the  time-honored  Basham's 
Mixture  in  the  anaemia  of  nephritis,  and  I  have  seen  no  re- 
sults from  internal  medication  in  anaemias  resulting  from 
cirrhosis  of  the  liver,  malignant  disease,  or  any  other  incur- 
able organic  lesion. 

The  direct  transfusion  of  blood  is  a  measure  of  the  greatest 
importance  in  the  treatment  of  the  rather  rare  cases  of  grave 
posthaemorrhagic  anaemia  which  show  no  considerable  tend- 
ency to  spontaneous  improvement  after  the  haemorrhage 
has  ceased.  Some  of  these  cases  are  complicated  by  such 
extreme  weakness  of  the  stomach,  manifested  as  vomiting  or 
constant  nausea,  that  we  cannot  nourish  the  patient  properly 
until  his  anaemia  has  been  relieved  by  the  transfusion.  In 
such  cases  direct  transfusion  may  be  a  life-saving  operation. 
In  my  experience  the  operation  is  much  more  easily  performed 
if  a  vein  is  attached  to  another  vein  rather  than  to  an  artery. 
The  blood  can  always  be  made  to  flow  freely  from  the  vein  if 
its  ordinary  channel  of  return  is  obstructed.  Transfusion  is 
also  of  value  in  the  anaemias  accompanied  by  continuous 
oozing  as  from  an  ulcerated  intestine  or  ulcerative  stomatitis. 
Occasionally  the  prolonged  oozing  which  complicates  diseases 
associated  with  jaundice  may  be  also  checked  by  transfusion. 
The  patient  usually  gets  the  full  benefit  of  the  blood  trans- 
fused and  does  not  lose  any  of  it  by  haemolysis  if  we  are  deal- 
ing with  the  types  of  anaemia  just  mentioned. 

On  the  other  hand,  in  the  haemolytic  types  of  anaemia,  such 
as  pernicious  anaemia,  transfusion  is  not  only  valueless  but 
harmful. 

Despite  the  firm  and  widely-spread  belief  that  iron  is  of 
value  in  all  types  of  secondary  anaemia,  I  cannot  say  that  I 
have  ever  been  able  to  witness  any  benefit  from  its  use  except 


260  CASE   HISTORIES    IN   MEDICINE. 

in  chlorosis.  In  the  other  types  of  anaemia,  secondary  to 
curable  organic  diseases,  the  deficiency  of  blood  is  made  up 
as  soon  as  adequate  nutrition  is  secured  and  maintained. 
Whenever  iron  is  given,  whether  for  chlorosis  or  for  some  of 
the  other  types  of  secondary  ansemia,  freshly  prepared  Blaud's 
Mass  should  be  given  in  lo-grain  doses  three  times  a  day  after 
meals.  After  a  week's  time  this  dose  should  be  increased  to 
15  grains  three  times  a  day.  Doses  of  this  size  are  much 
more  effective  than  the  smaller  ones  usually  given.  The 
modern  so-called  organic  preparations  of  iron  have  no  ad- 
vantage except  their  expense,  which  renders  them  attractive 
to  a  certain  type  of  patient.  Out  of  many  thousand  patients 
treated  with  preparations  of  iron  I  have  known  but  one  or 
two  who  had  any  difficulty  in  taking  the  5-grain  pills  of 
Blaud's  Mass  in  the  method  just  suggested.  These  few  cases 
have  always  been  able  to  take  the  drug  in  the  form  of  re- 
duced iron,  I  or  2  grains  after  each  meal,  in  pill  form. 

Foreign  observ^ers  are  enthusiastic  over  the  results  of  high 
altitude,  in  the  treatment  of  ansemia.  Whether  the  altitude 
itself  has  any  effect  aside  from  the  stimulus  to  the  whole 
organism  resulting  from  the  change  of  climate  which  high 
altitude  usually  involves,  it  is  very  difficult  to  determine. 

Drugs  have  considerable  value  in  the  treatment  of  some  of 
the  minor  symptoms  of  anaemia,  such  as  anorexia,  insomnia, 
and  constipation.  The  ordinary  stomachics,  laxatives,  and 
hypnotics  have  no  better  field  of  action  than  in  such  cases. 

For  the  purpura  which  complicates  these  cases  no  treat- 
ment is  necessary.  The  haemorrhages  will  cease  as  soon  as 
the  patient's  general  condition  improves.  They  are  in  them- 
selves of  no  harm  to  the  patient. 


DISEASES   OF    UNKNOWN   ORIGIN.  26 1 

Case  96.  A  married  woman,  forty-three  years  old,  is  seen 
April  9.  Family  history  negative.  Has  had  three  children, 
the  youngest  now  twenty  years  old,  and  no  miscarriages. 
Eighteen  years  ago  she  began  to  suffer  from  profuse  men- 
struation which  became  so  excessive  and  exhausting  that 
eighteen  months  ago  the  uterus  and  appendages  were  re- 
moved. In  spite  of  the  cessation  of  the  haemorrhages  she 
says  that  she  has  lost  ground  and  grown  paler  more  rapidly 
since  the  operation.  For  the  past  six  months  nosebleeds 
have  been  frequent  and  at  times  so  excessive  that  the  nares 
have  been  plugged.  She  has  had  "  feverish  turns,"  lasting 
several  days  at  a  time,  but  her  chief  complaint  has  been  of 
weakness,  great  dyspnoea,  palpitation,  and  attacks  of  faint- 
ness.  Micturition  has  been  more  frequent  for  the  past  few 
years,  but  without  any  polyuria.  Her  legs  and  ankles  have 
been  considerably  swollen,  but  this  has  been  much  less  appar- 
ent lately.  About  a  month  ago  she  had  a  copious  epistaxis, 
followed,  four  days  later,  by  a  second,  less  severe,  and  has 
remained  in  bed  ever  since.  Her  temperature  was  first  taken 
March  28,  when  it  was  found  to  be  slightly  above  normal. 
Without  discoverable  local  cause,  it  rose  steadily  till  it  reached 
103°  six  days  later.  It  fell  to  normal  two  days  later,  but  the 
evening  record  has  since  been  several  times  as  high  as  99.4°. 
With  the  rise  in  her  temperature,  her  color,  previously  very 
pale,  became  like  that  of  parchment,  but  the  conjunctivae  re- 
mained white.  She  was  greatly  exhausted  and  somewhat 
delirious,  vomiting  occasionally  either  food  or  bile-stained 
mucus.  A  very  grave  prognosis  was  at  this  time  given  by 
the  attending  physician. 

When  seen  April  9,  patient  reported  herself  as  feeling  very 
well,  and  her  mental  condition  was  bright.  She  was  markedly 
anaemic,  but  with  only  a  slight  yellow  tinge  remaining.  The 
tongue  and  mucous  membranes  were  very  pale.  There  was 
a  deep  ulceration  on  the  left  side  of  the  nasal  septum  and 
several  crusts  were  seen  on  the  right.  A  systolic  murmur  was 
heard  in  the  vessels  of  the  neck.  The  heart's  apex  was  in  the 
fifth  space  in  the  nipple  line.  The  cardiac  dulness  extended 
a  finger's  breadth  and  a  half  to  the  right  of  sternum.  A 
systolic  murmur  was  heard  all  over  the  precordia,  rough  over 


262  CASE   HISTORIES   IN   MEDICINE. 

the  base,  but  becoming  softer  as  the  apex  was  approached  and 
transmitted  a  short  distance  into  the  axilla.  The  pulmonic 
second  was  slightly  accentuated.  The  upper  border  of  the 
liver  was  at  the  fifth  rib,  and  its  smooth  edge  could  be  felt 
two  fingers'  breadth  below  the  costal  margin.  The  edge  of 
the  spleen  was  readily  palpated.  The  ankles  were  slightly 
cedematous.  The  ophthalmoscope  showed  a  normal  fundus. 
Physical  examination  was  otherwise  negative. 

Urine,  specific  gravity  1012,  pale,  acid,  contains  the  slight- 
est possible  trace  of  albumin.  Sediment  slight,  consisting 
of  leucocytes,  and  a  rare  normal  red  cell;  no  casts.  A  blood 
count  on  April  3  showed  300,000  reds,  5400  whites,  Hgb. 
10%.  A  differential  count  of  400  whites  showed  polymorpho- 
nuclear 72%,  large  mononuclear  12%,  small  mononuclear 
15%,  eosinophiles  1%.  Ten  megaloblasts,  5  normoblasts, 
and  3  microblasts  were  seen.  Poikilocytosis,  macrocytosis, 
and  polychromatophilia  were  present.  A  second  count  made 
to-day  showed  1,000,000  reds,  5800  whites,  Hgb.  25%,  A 
differential  count  of  300  white  cells  showed  no  special  change 
In  the  proportions.  Four  megaloblasts,  11  normoblasts,  and 
2  microblasts  were  found. 

1.  What   are  the   common   causes   of   frequent   micturition 

In  women  and  In  men?  In  women,  (a)  nervousness 
and  debility  from  any  cause;  (b)  less  often  cystitis 
("simple,"     gonorrhoeal,     tuberculous,     or    calculous); 

(c)  the  pressure  of  the  pregnant  uterus  or  other  tumors; 

(d)  pyelitis  (tuberculous  or  septic).  In  men,  (a)  pros- 
tatic obstruction  and  its  results;  {b)  cystitis  (gonorrhoeal, 
tuberculous,  etc.);  (c)  pyelitis  (as  in  women).  Occa- 
sionally, in  either  sex,  chronic  nephritis  may  produce 
frequent  as  well  'as  profuse  micturition. 

2.  What  are  the  possible  causes  of  a  systolic  murmur  like 

that  here  described?  (a)  Arteriosclerotic  roughening 
of  the  aortic  arch  or  of  the  aortic  valves;  (b)  Anaemia 
and  other  causes  of  insufficient  muscular  contraction 
of  the  valve  orifices  (but  such  murmurs  are  usually 
louder  in  the  pulmonary  area),  (c)  Aneurism  of  the 
aorta;  (d)  aortic  stenosis  {provided  always  that  other 
signs  of  that  lesion  are  present,  thrill  and  plateau  pulse 
especially). 

3.  How  are  the  "  feverish  turns  "   to  be  explained  In  this 


DISEASES   OF   UNKNOWN   ORIGIN.  263 

case?  Fever  in  chronic  anaemia,  especially  pernicious 
anaemia,  is  not  uncommon.  After  any  profuse  haemor- 
rhage it  may  occur  especially  in  neurotic  persons. 

Diagnosis:  The  blood  is  characteristic  of  pernicious  anae- 
mia. The  haemorrhages  are  probably  symptoms,  not  causes, 
of  the  anaemia,  for  such  a  blood  picture  rarely  if  ever  results 
from  haemorrhage  of  the  type  here  described.  The  respira- 
tory, cardiac,  and  digestive  symptoms,  as  well  as  the  oedema, 
weakness  and  fever  can  be  explained  by  the  anaemia.  Other 
diseases  are  excluded  by  the  absence  of  physical  signs  point- 
ing to  them. 

Prognosis:  Of  700  cases  of  pernicious  anaemia  studied  by 
the  writer,  through  private  practice  and  in  literature,  298 
were  known  to  have  lived  less  than  one  year,  258  lived  from 
one  to  three  years,  and  143  lived  over  three  years.  Of  the 
latter  group  10  lived  more  than  seven  years,  4  more  than 
eight  years,  6  lived  nine  years,  and  17  lived  ten  years  or 
more.  Since  relapse  had  been  known  to  occur  even  after 
the  interval  of  seventeen  years,  we  can  scarcely  venture  to 
speak  of  any  case  as  having  been  cured,  I  have  known 
3  cases  which  relapsed  after  four  years  or  more  of  perfect 
health.  Probably  the  average  duration  is  less  than  two 
years,  but  it  Is  difficult  to  be  quite  certain  on  this  point,  since 
the  beginning  of  the  disease  can  rarely  be.  fixed. 

Periods  of  Improvement  sometimes  so  striking  as  to  seem 
almost  miraculous,  occur  In  about  85%  of  all  the  cases. 
Among  524  cases  which  I  have  studied  in  detail,  there  was 
one  such  wave  of  improvement  In  296,  two  waves  in  118, 
three  In  65,  four  in  21,  and  five  In  24.  There  may  be  great 
improvement  In  the  patient's  feelings  and  symptoms  with- 
out a  corresponding  change  In  the  blood  picture,  or,  more 
rarely,  the  conditions  may  be  reversed.  These  remissions 
usually  last  from  three  to  twelve  months  and  may  occur  at 
any  period  In  the  year,  having  no  special  preference  for  the 
warmer  season. 

Treatment:  Rest  seems  to  be  of  undoubted  benefit.  Many 
patients  have  gone  on  steadily  from  bad  to  worse  so  long  as 
they  continued  at  work,  but  showed  evidence  of  improvement 
soon  after  they  had  given  up  and  taken  to  bed. 


264  CASE   HISTORIES   IN   MEDICINE. 

Good  hygiene,  including  abundance  of  nourishing  foods  of 
all  types,  and  a  life  lived  as  much  as  possible  in  the  open  air, 
has,  I  believe,  some  favorable  influence  upon  the  course  of 
the  disease.  Special  limitations  of  diet,  such  as  have  been 
suggested  by  Herter  and  others,  have  not  proved  of  any 
definite  value. 

Most  physicians  believe  that  arsenic  has  a  distinctly  favor- 
able influence  upon  the  disease  in  that  it  delays  the  fatal 
issue  and  promotes  the  occurrence  of  temporary  remissions. 
Though  I  have  given  the  drug  in  several  hundred  cases  and 
shall  continue  to  do  so  until  some  better  treatment  is  sug- 
gested, I  am  by  no  means  confident  that  it  has  any  distinct 
action,  since  the  tendency  to  spontaneous  improvement  is  so 
very  marked  in  most  cases.  There  seems  to  be  no  advan- 
tage in  any  of  the  more  recent  synthetic  preparations  of 
arsenic,  such  as  atoxyl,  salvarsan,  or  sodium  cacodylate. 
Bone  marrow  and  oxygen  are  certainly  useless  and  trans- 
fusion of  blood  does  harm.  Arsenic  is  best  given  in  the 
form  of  Fowler's  Solution,  beginning  with  2  drops  well  diluted 
after  meals,  and  increasing  I  drop  a  day  (not  i  drop  after 
each  meal)  until  the  limit  of  toleration  has  been  reached. 
Few  patients  can  get  past  15  drops  three  times  a  day,  but  the 
few  who  can  exceed  this  dose  are  those  who  are  most  likely  to 
see  an  apparent  benefit. 


DISEASES   OF  UNKNOWN   ORIGIN.  265 

Case  97.  A  girl  of  fifteen,  seen  February  15,  1905,  had 
typhoid  a  year  ago,  was  five  weeks  in  bed,  had  a  fine  post- 
typhoid appetite  and  seemed  splendidly  through  the  summer 
and  the  autumn.  In  the  middle  of  January,  1905,  it  was 
noticed  that  she  was  very  white,  especially  after  gymnasium 
classes  which  took  away  her  appetite  for  supper.  Her  men- 
struation, previously  regular  since  the  age  of  thirteen,  now 
became  irregular  and  she  lost  some  flesh.  The  urine,  exam- 
ined January  25,  was  found  to  contain  a  slight  trace  of  albu- 
min and  a  few  granular  casts.  Similar  findings  were  obtained 
February  6.  She  was  taken  out  of  school  three  weeks  ago 
and  has  improved  since  that  time.  She  has  no  headache  and 
no  other  pains,  her  appetite  is  now  good  and  there  has  been 
no  oedema.  Bowels  tend  to  be  costive.  Her  best  weight, 
114;  present  weight  109.  She  has  grown  an  inch  and  a  half 
in  the  last  six  months. 

On  February  19  the  urine  passed  just  after  rising  in  the 
morning  contained  no  albumin  but  the  evening  specimen  was 
albuminous.  A  small  number  of  hyalin  casts  were  found. 
July  19  there  was  no  albumin  either  night  or  morning.  Octo- 
ber 21,  1905,  there  was  no  albumin  in  the  morning  but  a 
slight  trace  at  night.  On  neither  occasion  were  there  any 
casts.  The  examination  of  the  heart  and  the  other  internal 
viscera  as  well  as  of  the  blood  was  at  all  times  wholly 
negative. 

I.  What  considerations  should  influence  us  in  estimating  the 
significance  of  this  albuminuria?  We  must  make  sure, 
in  the  first  place,  that  the  albumin  is  not  due  to  any 
admixture  of  vaginal  discharge.  This  can  be  done  by 
securing  catheter  specimens.  If  these  still  show  albumin 
we  have  to  distinguish  chiefly  between  the  albuminuria 
of  adolescence  and  that  due  to  some  type  of  nephritis. 
Experience  shows  that  albumin  appearing  near  the  time 
of  puberty  often  disappears  within  a  few  years  with- 
out the  occurrence  of  any  other  symptoms  of  the 
disease.  This  is  especially  true  when  it  is  of  the  so- 
called  orthostatic  type  appearing  after  the  patient  has 
been  for  some  time  in  the  upright  position  —  i.e.,  in 
the  afternoon  and  evening  —  and  disappearing  during 
recumbency. 


266  CASE   HISTORIES   IN   MEDICINE. 

The  presence  of  casts  does  not  prove  that  any  nephritis 
exists,  though  in  many  of  the  orthostatic  albuminurias  we 
find  no  casts.  Most  important  of  all  is  the  condition  of  the 
heart  and  peripheral  vessels.  If  there  is  no  hypertrophy 
and  no  hypertension  after  at  least  six  weeks  of  albuminuria, 
we  may  usually  conclude  that  no  considerable  damage  has 
been  done  to  the  kidney. 

The  patient  was  seen  in  January,  1906,  and  had  then  no  al- 
bumin. February,  1907,  no  albumin.  October,  1907,  no  albu- 
min. January,  1909,  no  albumin.  Evidently,  therefore,  this 
alarming  symptom  passed  off  with  the  period  of  adolescence. 

Prognosis:  Experience  seems  to  show  that  we  can  give  a 
wholly  favorable  prognosis  when  the  conditions  are  as  above 
described. 

Treatment:  There  is  no  reason  for  restricting  the  diet  or 
for  administering  any  drug.  As  with  any  other  child  who 
shows  the  stress  of  adolescence  either  in  mind  or  body,  we 
should  let  up  upon  the  load,  diminish  the  amount  of  effort 
in  school  or  out  of  school  and  allow  the  child  to  catch  up 
with  nature. 


DISEASES   OF   UNKNOWN   ORIGIN.  267 

Case  98.  A  Syrian  girl,  aged  14,  was  seen  January  21, 
1911.  The  family  history  and  past  history  were  negative. 
She  has  been  sick  for  five  months.  During  the  first  two 
months  of  this  time  she  had  diarrhoea  with  ten  or  eleven 
movements  a  day.  No  blood  was  seen  in  the  discharges. 
After  the  diarrhoea  ceased  she  was  unable  to  walk  on  account 
of  weakness ;  this  has  been  so  great  for  the  past  six  weeks  that 
she  has  been  obliged  to  remain  in  bed.  For  the  past  eight 
days  she  has  had  an  increasingly  sore  throat.  Except  for 
this,  her  only  complaint  during  the  past  three  months  has 
been  of  weakness.  Before  this  illness  she  weighed  100  pounds. 
At  Christmas,  1910,  she  weighed  90  pounds,  now  80  pounds. 

On  examination  the  girl  was  very  pale  and  sallow.  The 
pupils  were  normal.  There  was  no  glandular  enlargement. 
The  left  tonsil  was  covered  by  a  dirty  whitish  membrane 
which  also  extended  down  the  uvula  and  a  short  distance 
on  the  soft  palate.  The  heart's  dulness  extended  i  cm.  out- 
side the  nipple  line  in  the  fifth  space,  corresponding  with 
the  limit  of  the  palpable  apex  impulse.  A  systolic  mur- 
mur, loudest  in  the  pulmonary  area,  was  audible  over  the 
whole  precordia.  Over  the  lower  half  of  the  sternum  a 
high-pitched  diastolic  murmur  was  also  heard.  The  systolic 
murmur  was  clearly  audible  in  the  right  back.  Visceral  ex- 
amination was  otherwise  negative.  The  urine  averaged  30 
ounces  in  24  hours,  with  a  gravity  between  1012  and  1014, 
slightest  possible  trace  of  albumin,  no  casts.  For  three  weeks 
the  patient  ran  a  continuous  fever  averaging  103°  the  first, 
102°  the  second,  101°  the  third.  The  pulse  ranged  through- 
out in  the  neighborhood  of  120. 

At  the  beginning  of  the  illness  the  red  cells  numbered 
1,200,000;  two  weeks  later  they  had  fallen  to  750,000.  The 
white  cells  were  in  the  neighborhood  of  2000;  haemoglobin  at 
first  30%,  later  20%.  The  polynuclear  cells  were  persist- 
ently diminished  in  number;  40%  were  found  at  entrance 
and  25%  in  the  latter  portion  of  the  illness.  The  absolute 
number  of  lymphocytes  was  never  far  from  normal.  The 
blood-plates  numbered  50,000  on  the  23d  of  January,  60,000 
on  the  29th.  The  stained  smear  showed  practically  normal 
red  cells  without  any  achromia  and  with  but  slight  deformities. 


268  CASE   HISTORIES   IN   MEDICINE. 

In  three  out  of  four  examinations  during  three  weeks  no 
nucleated  red  cells  were  found.  At  the  fourth  examination 
two  normoblasts  were  seen.  The  throat  showed  invariably 
negative  cultures  for  Klebs-Loffler  and  for  the  organism  of 
Vincent's  angina.  The  prevailing  germ  was  the  staphylococ- 
cus. The  Wassermann  reaction  was  negative.  In  the  third 
week  of  the  illness  the  membrane  grew  smaller  and  smaller 
and  finally  disappeared,  leaving  a  dark  colored  excavation. 

Diagnosis :  Clearly  we  are  dealing  with  a  profound  anaemia, 
the  cause  of  which  is  very  obscure.  It  does  not  appear  that 
the  prolonged  diarrhoea  with  which  her  illness  began  was  it- 
self the  cause  of  the  anaemia,  since  the  latter  has  persisted  and 
advanced  although  the  bowels  have  been  regular  for  the  past 
three  months.  Probably  the  diarrhoea  was  a  symptom  of  an 
already  existing  anaemia.  A  haemolytic  anaemia  due  to  septic 
absorption  from  the  throat  was  also  considered,  but  on  more 
careful  study  it  appeared  that  this  local  inflammation  in  the 
throat  did  not  show  itself  until  the  patient  had  been  suffer- 
ing for  some  weeks  from  a  disease  which  in  all  probability  was 
anaemia.  The  throat  membrane,  like  the  diarrhoea,  is  best  ex- 
plained as  the  result  rather  than  the  cause.  The  age  of  the 
patient,  the  rapid  progress  of  the  symptoms,  and  the  character 
of  the  blood  all  point  to  the  type  of  anaemia  known  as  aplastic. 

Prognosis  and  Treatment:  Aplastic  anaemia  carries  a  worse 
prognosis  than  the  ordinary  types  of  pernicious  anaemia. 
There  are  rarely  any  periods  of  remission,  as  in  the  latter 
disease,  and  the  duration  of  life  is  rarely  more  than  six  months. 
Treatment  has  so  far  proved  unavailing.  This  little  girl  died 
on  the  nth  of  February  and  autopsy  showed  a  bone  marrow 
almost  pure  white  with  marked  fatty  degeneration  of  the 
heart,  and  some  hypertrophy  and  dilatation  of  that  organ. 


DISEASES   OF    UNKNOWN   ORIGIN.  269 

Case  99.  A  banker,  fifty-eight  years  old,  of  good  family 
and  previous  history,  of  good  habits  except  for  very  rapid 
eating,  is  seen  May  i.  About  a  year  ago  his  remaining  teeth, 
which  were  few  and  inefHcient,  were  extracted.  False  teeth 
were  procured,  but  he  has  not  been  able  to  wear  them  on 
account  of  sore  mouth,  apparently  subjective  rather  than 
objective.  His  wife  states  that  for  at  least  a  year  he  has  not 
been  as  vigorous  as  formerly.  He  says  that  during  the  sum- 
mer his  sleep  was  poor,  without  apparent  cause.  In  June  he 
took  a  vacation,  but  returned  weaker  than  when  he  went, 
complaining  of  poor  appetite  and  digestion,  nausea,  and  occa- 
sional vomiting.  The  vomitus  was  not  characteristic.  He 
did  not  gain  in  the  summer  and  his  complexion  became  sallow. 
November  15,  after  drinking  moderately  of  cider,  diarrhoea 
came  on;  and  between  this  date  and  February  he  lost  fifty- 
one  pounds  in  weight.  Soon  after  this  the  diarrhoea  was 
checked,  and  since  the  last  of  February  loss  in  weight  has 
been  trifling,  though  his  color  and  strength  have  continued 
to  fail.  His  digestion  is  better,  and  he  takes  a  fair  amount 
of  food.  His  main  complaint  at  present  is  of  weakness,  lassi- 
tude, and  shortness  of  breath  on  slight  exertion.  No  fever 
has  been  noted.  Several  examinations  of  the  urine  have  been 
made,  all  negative  until  a  week  ago  when  a  single  specimen 
showed  specific  gravity  1008,  albumin  -iq%,  some  pus  —  not 
enough,  it  was  thought,  to  account  for  the  albumin  —  and  a 
few  hyalin  casts.  The  twenty-four-hour  amount  is  not 
known,  but  is  believed  by  the  attending  physician  to  be 
increased.  Pulse  84,  regular,  feeble,  and  of  low  tension. 
Temperature  99.6°.  Marked  pallor  of  skin  and  mucous  mem- 
branes, with  a  yellowish  tinge.  Soft  systolic  murmurs  are 
heard  in  the  mitral  and  pulmonic  areas;  the  heart  is  not 
enlarged.  There  is  slight  oedema  of  the  ankles.  Visceral 
examination  is  otherwise  negative. 

1 .  What  chronic  diseases  are  most  prone  to  appear  at^  fifty- 

eight?     Cancer,  pernicious  anaemia,  arteriosclerosis  and 
its  results. 

2.  What  seems  to  account  for  the  diarrhoea  ?     (See  diagnosis.) 

3.  What  Is  the  significance  of  a  urine  of  low  specific  gravity? 

Profuse  Ingestion  of  fluid,  nervousness,   chronic  Inter- 
stitial nephritis,  diabetes  insipidus. 


270  CASE   HISTORIES   IN   MEDICINE. 

Diagnosis :  Yellowish  pallor,  weakness,  and  dyspnoea,  with 
no  obvious  disease  of  the  heart  or  lungs,  suggest  grave  anaemia. 
The  urinary  abnormalities  are  too  recent  to  account  for  the 
symptoms.  Gastro-intestlnal  symptoms  such  as  are  here  de- 
scribed often  occur  in  anaemia.  The  cider  had  probably  no 
effect.     Blood  examination  revealed  typical  pernicious  anaemia. 

Prognosis  and  Treatment :  (see  above,  Case  96). 


DISEASES   OF    UNKNOWN   ORIGIN.  27 1 

Case  100.  A  business  man  of  twenty-six,  of  good  family 
history,  habits,  and  previous  health,  is  seen  in  November, 
1900.  In  the  latter  part  of  July,  after  golf,  which  he  plays 
with  the  left  hand  down,  he  suffered  during  part  of  the  night 
from  severe  pain  throughout  the  left  arm.  A  month  later  he 
had  a  similar  attack,  not  following  golf,  and  vhe  pain  then 
recurred  nightly  after  i  a.m.  During  the  daytime  the  pain 
was  only  occasional.  About  eight  weeks  ago  he  began  to 
have  "  indigestion  "  —  i.e.,  a  sensation  as  if  food  was  arrested 
on  its  way  to  the  stomach,  which,  apparently,  managed  it 
well  enough  after  its  arrival.  About  two  weeks  later  a  dry, 
harassing  cough  came  on,  troubling  him  most  when  on  his 
back  or  right  side,  but  also  excited  by  taking  food.  Soon 
after  this  he  noticed  that  the  veins  in  his  neck  swelled  up 
when  he  stooped  over,  and  he  had  to  have  his  head  higher  at 
night.  Lately  he  has  had  severe  night  sweats.  Pain,  espe- 
cially in  his  left  arm,  dysphagia,  and  dry  cough  are  now  the 
most  prominent  symptoms.  There  has  been  some  loss  of 
weight,  more  of  strength. 

He  is  pale,  nervous,  and  excited.  The  pulse  and  respiration 
are  normal  in  the  erect  position.  Lying  down  causes  marked 
dyspnoea.  Toward  the  root  of  the  neck  on  the  left  side  dis- 
crete, nontender  lumps  can  be  felt,  without  attachment  to 
or  reddening  of  the  skin.  Percussion  is  dull  over  the  upper 
sternum,  without  prominence  or  pulsation.  The  radials  are 
synchronous  and  equal  in  volume;  the  pupils  are  equal;  there 
is  no  tracheal  tug.  Thoracic  and  abdominal  exploration  is 
otherwise  negative.  So  also  the  urine.  The  axillary  and 
inguinal  glands  are  not  enlarged.  Haemoglobin  70%;  reds 
4,500,000;  whites  22,300, 

1.  What  is  the  significance  of  pain  which  is  worse  at  night? 

Congestive  pain,  such  as  tooth-ache,  the  pain  of  certain 
headaches,  and  of  syphilitic  periostitis,  is  increased  by 
a  position  that  brings  more  blood  to  the  part.  Any 
relatively  mild  pain  Is  felt  more  severely  at  night  be- 
cause of  the  absence  of  distraction. 

2.  What  temperature  should  you  expect  in  this  case  ?     Slight, 

irregular  fever. 

3.  What  importance  has  the  age  of  this  patient?     Cancer  and 

aneurism  are  unlikely  at  twenty-six. 


272  CASE   HISTORIES   IN   MEDICINE. 

Diagnosis:  Pain  in  the  left  arm,  dysphagia,  dyspnoea,  dry 
cough,  lumps  in  the  neck,  dulness  behind  the  sternum,  marked 
increase  of  leucocytes  are  the  important  data  here,  and  all 
suggest  aneurism  or  mediastinal  tumor.  Aneurism  is  rare  at 
twenty-six  years  and  does  not  produce  leucocytosis  or  lumps  in 
the  neck.  Hodgkins'  disease  and  leucaemia  are  identical  but  for 
the  blood.  In  this  case  the  blood  showed  lymphocytes  65.2%, 
polynuclears  34%,  eosinophiles  and  myelocytes  each  4%. 
Lymphatic  leucaemia  is  accordingly  the  diagnosis.  Most  of 
the  lymphocytes  were  of  the  small  type. 

Prognosis :  The  prognosis  of  the  small  cell  type  of  lymph- 
oid leucaemia  is  distinctly  more  favorable  since  the  intro- 
duction of  the  X-ray  treatment.  But  even  without  that, 
I  have  known  patients  to  live  tw^o  years  or  more  in  entire 
comfort  and  actively  at  work.  Probably  the  majority  even 
of  the  so-called  chronic  cases  terminate  within  two  years. 
As  a  rule  the  lymphoid  type  of  the  disease  tends  to  run  a 
much  shorter  course  than  the  myeloid.  Cases  of  acute  lymph- 
oid leucaemia  are  not  uncommon,  while  cases  of  the  acute 
myeloid  form  of  the  disease  are  very  rare. 

Spontaneous  improvement  without  any  treatment  what- 
ever has  been  repeatedly  observed  and  may  bring  the  patient 
back  apparently  to  perfect  health  with  a  normal  blood 
picture.  Such  waves  of  improvement,  however,  are  never 
lasting  and  occur  only  In  a  small  minority  of  cases  without 
treatment.  Improvement  Is  much  more  likely  to  occur 
following  the  administration  either  of  arsenic  or  of  X-ray 
treatment.  If  arsenic  is  given,  It  may  be  administered  pre- 
cisely in  the  manner  suggested  under  the  treatment  of  per- 
nicious anaemia. 

X-ray  exposures  are  of  the  greatest  value  in  delaying  the 
course  of  the  disease,  though  no  cures  have  occurred,  and  we 
have  no  good  reason  to  expect  any,  since  the  X-ray  acts  only 
by  destroying  the  leucocytes  in  the  spleen,  marrow,  and 
elsewhere,  and  has,  so  far  as  we  know,  no  action  upon  the 
unknown  cause  which  brings  about  the  over-production  of 
cells.  Much  more  satisfactory  results  are  obtained  if  we  can 
secure  the  services  of  an  experienced  operator,  practiced  In 
the  application  of  X-rays  to  this  particular  disease.     Daily 


DISEASES  OF   UNKNOWN   ORIGIN.  273 

exposures  are  in  my  experience  most  likely  to  produce 
improvement.  As  to  the  details  of  the  type  of  tube  and 
methods  of  protecting  the  skin,  I  do  not  feel  competent  to 
speak.  Each  operator  has  his  own  methods  in  these  respects. 
Treatment  should  be  continued  until  the  blood  picture  is 
markedly  improved.  It  may  then  be  given  less  frequently 
and  finally  discontinued,  but  as  a  rule  must  be  kept  up  at 
least  once  a  week  during  the  patient's  lifetime.  The  por- 
tions to  be  exposed  are  the  spleen  when  this  is  enlarged,  the 
superficial  lymph  glands  if  these  are  hypertrophied,  and  in 
all  cases  the  marrow  of  the  long  bones. 


CHAPTER  IX. 

NOTES  ON  DRUG  THERAPY. 

I  HAVE  neither  time,  space,  nor  knowledge  for  anything 
like  adequate  treatment  of  the  subject  of  drug  therapeutics. 
I  wish  to  comment  briefly  on  the  following  topics: 

(i)  The  present  outlook  for  drug  therapy. 

(2)  Placebos. 

(3)  The  homoeopathic  principle  and  modern  dosage. 

(4)  The  existing  use  of  drugs  at  the  Massachusetts  General 
Hospital. 

I. 

A  new  era  in  clinical  therapeutics  dawned  with  the  re- 
searches of  Ehrlich,  which  culminated  in  the  appearance  of 
salvarsan.  Great  as  is  the  importance  of  this  drug  as  a 
cure  for  syphilis,  it  seems  to  me  still  more  important  as  a 
triumph  of  systematic  experimental  work.  Salvarsan  was 
not  discovered  by  accident;  on  the  contrary,  it  represents 
the  result  of  the  6o6th  attempt  to  make  synthetically  just 
such  a  substance.  Atoxyl  was  a  much  earlier  link  in  the 
same  chain  of  constructive  endeavors. 

Pretty  much  all  of  the  drugs  in  the  pharmacopoeia  were 
stumbled  upon  more  or  less  accidentally.  Not  one,  so  far  as 
I  know,  was  elaborated  as  the  result  of  pure  synthetic  chemis- 
try searching  for  a  substance  that  would  kill  a  particular 
microorganism  without  injuring  the  other  tissues  of  the 
body.     This  is  apparently  what  salvarsan  does. 

It  has  a  part  that  kills —  "  a  business  end  "  —  a  part 
that  fatally  fits  (like  a  key  in  a  lock)  into  the  vitals  of  the 
Treponema  pallidum  (and  certain  allied  organisms) ,  but  not 
into  any  one  of  the  normal  cells  of  the  human  body.  Its 
poisonous  arsenic  passes  by  every  cell  in  the  body  except  the 
organism  of  syphilis;  for  that  it  is  fatal,  for  the  rest  harmless. 

274 


NOTES  ON  DRUG  THERAPY.  275 

Now  It  certainly  seems  reasonable  to  believe  that  a  scien- 
tific method  that  can  build  up  one  such  compound  can  elabo- 
rate others  of  something  like  equal  efficiency  In  other  diseases. 
Already  (as  Dr.  Flexner  announced  last  May,  at  the  Asso- 
ciation of  American  Physicians)  attempts  are  being  made  to 
graft  onto  hexamethylentetramlne  (which  seems  to  penetrate 
Into  the  tissues  where  the  poison  of  poliomyelitis  abides) 
some  complex  which  will  do  for  Infantile  paralysis  what  sal- 
varsan  does  for  syphilis.  Vistas  loom  up  of  pure  chemical 
therapy,  scientific,  rational,  free  from  harmful  by-effects. 

Most  of  the  powerful  germicides,  such  as  mercury,  have  dis- 
agreeable, sometimes  serious,  by-effects.  The  organic  prepa- 
rations, such  as  thyroid  extract  and  diphtheria  antitoxin,  are 
not  chemically  pure,  and  the  111  effects  which  they  sometimes 
produce  will  doubtless  continue  to  plague  us  until  we  can 
Isolate  some  crystalllzable  substance  as  the  "  active  prin- 
ciple "  of  the  mass. 

Up  to  the  epoch  opened  by  salvarsan,  all  of  the  most  valu- 
able remedies  discovered  during  the  last  thirty  years  were 
derived  from  the  animal  body  and  were  therefore  biological 
rather  than  purely  chemical  products.  Salvarsan  is  free  from 
most  of  the  defects  of  these  substances,  and  our  knowledge  of 
its  structure  and  properties  Is  far  more  complete. 

I  look  for  a  great  Increase  In  the  number  of  such  drugs 
within  the  next  twenty  years,  and  consequently  for  a  rebirth 
of  our  waning  faith  in  the  pharmacopoeia.  Never,  I  believe, 
has  the  outlook  for  purely  chemical  therapy  (as  opposed  to 
surgery  and  other  mechanical  types  of  cure)  been  as  good  as 
at  the  present  time. 

II. 

Placebos  —  inert  or  harmless  drugs  used  for  their  mental 
effect,  as  a  means  of  suggestion  —  are  doubtless  destined  to 
be  extensively  employed  by  the  medical  profession  in  the 
future  as  in  the  past.  Their  value  consists,  of  course,  in  the 
fact  that  through  them  the  physician  can  fool  the  patient, 
often  for  his  own  good.  But  whether  one  objects  (as  I  do) 
to  this  form  of  lying  or  not,  one  cannot  but  see  a  gain  in 
the  fact  that  these  placebos  no  longer  fool  as  many  physicians 


276  CASE   HISTORIES   IN   MEDICINE. 

as  was  once  the  case.  When  a  doctor  uses  a  useless  drug 
he  is  far  more  apt  nowadays  to  know  just  what  he  is  doing 
than  he  was  twenty  years  ago.  He  knows  his  placebos 
from  his  physiologically  active  drugs.  He  knows  just  when 
he  is  lying  and  when  he  is  playing  a  straightforward  part. 

Some  are  even  more  sanguine  than  this  and  venture  to 
believe  that  placebos  are  not  only  recognized  but  repudiated 
by  physicians.  Thus  the  Journal  of  the  American  Medical 
Association  states  (September  16,  191 1,  page  990),  presumably 
through  its  Council  of  Pharmacy: 

''  The  specious  argument  that  the  public  '  calls  '  for  worth- 
less things  and  that  it  is  legitimate  to  supply  this  want,  was 
long  ago  repudiated  by  the  medical  profession." 

Obviously  the  argument  —  that  the  public  demands  to  be 
drugged  —  is  the  only  respectable  argument  for  the  use  of 
placebos,  and  if  the  medical  profession  has  repudiated  it  in 
theory,  perhaps  before  long  it  will  repudiate  it  in  practice  and 
give  no  more  placebos.  In  the  revision  of  the  present  year 
154  such  useless  articles  were  dropped  from  the  pharmacopoeia 
{American  Druggist,  August  28,  191 1),  leaving  only  about  850 
in  the  approved  list.  When  several  hundred  more  have  been 
dropped,  we  shall  begin  to  get  down  towards  the  level  of  gen- 
uine efficiency  and  sober  science  in  the  field  of  drug  therapy. 

Meantime  it  is,  as  I  believe,  a  great  gain  that  doctors  are 
beginning  themselves  to  distinguish  between  useful  and  use- 
less drugs,  avoiding  the  extremes  of  nihilistic  or  expectant 
treatment  on  the  one  side  and  credulous  over-drugging  on  the 
other. 

HI. 

The  homoeopathic  principle  "  similia  similihus  curentur  " 
and  the  minute  doses  still  used  by  a  minority  of  homoeo- 
pathic practitioners,  are  paralleled  closely  by  the  vaccine 
therapy  (especially  tuberculin  therapy)  which  has  come  into 
vogue  in  the  past  decade.  It  is  agreed,  as  it  seems  to  me,  by 
most  of  those  who  have  considered  these  facts,  that  the 
homoeopathic  dogma  is  sometimes  true.  On  the  other  hand, 
most  honest  homoeopaths  admit  that,  since  in  many  instances 
they  can  find  no  way  to  apply  their  principle,  they  must  often 


NOTES   ON   DRUG   THERAPY.  277 

fall  back  on  the  use  of  ordinary  drugs  in  ordinary  doses  used 
as  the  rest  of  us  use  them  —  independent  of  any  dogma. 

This  clears  the  ground  and  points,  I  hope,  to  the  ultimate 
extinction  of  sectarianism  in  medicine.  Specialism  even  in 
therapeutics  is  always  legitimate,  but  since  we  all  admit  nowa- 
days that  homoeopathy  sometimes  works  and  all  admit  that 
it  doesn't  always  work,  we  can  get  down  to  business.  We  can 
proceed  with  open  minds  to  determine  when  treatment  based 
on  the  principle  of  vaccine  therapy  (and  of  homoeopathy)  is 
effective  and  when  it  fails.  Having  no  prejudice  either  for 
or  against  any  special  method  of  using  drugs,  we  can  impar- 
tially examine  all  methods. 

Meantime  there  is,  of  course,  no  sense  In  pretending  that 
"  alkaloids  "  and  "  alkaloldal  therapy  "  have  any  superiority 
over  methods.  Castor  oil,  digitalis,  thyroid  extract,  diph- 
theria, antitoxin,  mercury,  aspirin,  iron  are  no  worse  for  not 
being  alkaloids. 

Dosage :  As  I  see  cases  w^Ith  other  physicians  and  ask  them 
about  their  treatment,  I  often  hear  that  they  are  giving  "  a 
little "  of  half  a  dozen  drugs  in  some  tablet  supplied  by  a 
well-known  drug  firm  —  a  little  iron,  a  little  arsenic,  a  little 
nux  vomica,  a  little  digitalis,  diuretin,  and  what  not.  As  a 
rule  the  dosage  is  so  small  that  the  remedy  cannot  possibly 
have  any  effect.  To  give  small  doses  because  they  are  small 
is  as  stupid  as  to  give  large  doses  because  they  are  large. 
The  only  sensible  dose  is  the  dose  which  is  found  to  accom- 
plish the  desired  result.  If  you  are  giving  a  diuretic  you 
should  give  enough  to  produce  diuresis  or  to  prove  that  you 
cannot  get  diuresis  with  that  drug  and  had  better  try  some 
other.  Drugs  should  be  given  with  definite  indications,  such 
as  pain  or  constipation,  and  pushed  till  the  symptom  is  alle- 
viated or  the  remedy  proved  useless. 

It  is  difficult  to  accomplish  this  when  we  are  giving  from 
three  to  six  drugs  at  once.  Hence  the  disadvantages  of  poly- 
pharmacy. To  find  out  whether  you  are  getting  good  from 
a  certain  drug  It  is  usually  necessary  to  avoid  giving  simul- 
taneously another  drug  intended  for  the  same  purpose.  To 
combine  digitalis  and  strophanthus,  iron  and  arsenic,  makes 
effective  dosage  very  difficult. 


278  CASE   HISTORIES   IN   MEDICINE. 

I  have  no  doubt  that  certain  drugs  —  especially  hypnotics 
and  anodynes  —  act  better  in  combination,  but  I  believe 
that  no  one  should  use  them  in  combination  until  he  has  had 
extensive  experience  with  the  individual  members  of  the  com- 
bination, used  separately. 

To  use  one  drug  for  one  purpose,  to  increase  the  dose 
until  you  have  accomplished  that  purpose  or  satisfied  yourself 
that  you  cannot  accomplish  it  with  that  drug,  and  then  to 
stop  it  —  such  methods  make,  I  believe,  for  better  results  in 
therapy. 

IV. 

Some  years  ago  I  asked  two  of  my  neighbors  at  a  dinner 
of  the  Association  of  American  Physicians  to  write  on  their 
dinner  cards  a  list  of  the  drugs  which  they  personally  believed 
to  be  valuable,  excluding  placebos.  Their  list  and  the  one 
which  I  wrote  at  the  same  time  were  so  nearly  identical  that 
I  became  interested  to  ask  other  physicians  whether  their 
working  list  of  remedies  was  approximately  the  same  and 
equally  small. 

Accordingly  I  have  prepared  the  following  list  which  con- 
tains the  drugs  actually  used  by  the  internists  connected 
with  the  Massachusetts  General  Hospital  in  the  treatment 
of  their  patients  during  the  last  four  years.  It  includes  the 
ingredients  of  about  50,000  prescriptions. 

I  find  that  the  drugs  of  this  particular  list  divide  themselves 
conveniently  into  the  following  groups: 

(I)  Specifics. 

(II)  Drugs   used   for  cardiac  weakness  and  to  combat 
dropsy. 
(Ill)   Drugs  used  for  pain. 
(IV)   Drugs  used  for  sleep. 
(V)   Purgatives  and  laxatives. 
(VI)  Drugs  used  in  diarrhoea  and  enteritis. 
(VII)  Drugs   used   for   their  supposed  effect  on  gastric 
function. 
(VIII)   Miscellaneous. 


NOTES  ON  DRUG  THERAPY. 


279 


I  have  omitted  all  the  drugs  used  as  general  or  local  anaes- 
thetics, antiseptics,  and  local  disinfectants  in  the  surgical 
wards  (e.g.,  ether,  corrosive  sublimate,  aristol,  zinc  oxide),  all 
those  used  for  their  local  action  as  emetics  or  in  diseases  of 
the  skin  or  mucous  membranes  (e.g.,  lanolin,  Dobell's  solu- 
tion, starch,  talc  powder,  ichthyol,  chrysarobin,  etc.),  or  for 
local  action  in  the  genito-urinary  tract,  the  eye,  the  nose,  etc. 

Leaving  these  out  of  account  I  have  listed  those  drugs  which 
seem  to  be  of  special  value  in  internal  medicine. 


DRUGS   USED   IN  THE   MEDICAL  WARDS  OF  THE 
MASSACHUSETTS  GENERAL   HOSPITAL.^ 


I.  Drugs    Believed    to    Have    Each    a 

Specific   Action    in   Relation   to   a 
Particular  Disease. 

1.  Quinin  in  malaria. 

2.  Salvarsan  in  syphilis. 

3.  Mercury  in  syphilis. 

4.  Potassic  iodid  ^  in  syphilis. 

5.  Iron  in  chlorosis.* 

6.  Diphtheria  antitoxin. 

7.  Tetanus  antitoxin. 

8.  Antimeningococcus  serum. 

9.  Staphylococcus  vaccine  (in  certain 

local  infections). 
10.   Typhoid  vaccine  (prophylactic  ac- 
tion only). 

II.  Small-pox    vaccine     (prophylactic 

action  only). 

12.  Thyroid  extract  in  myxoedema. 

13.  Pancreatic  extract  in  certain  types 

of  pancreatic  disease. 


9- 
10. 
II. 

12. 

13- 

14. 

15- 
16. 


Digipuratum. 

Strophanthin  (crystallized)  (occa- 
sionally). 

Strychnin  (and  nux  vomica). 

Nitrites  (nitroglycerin,  amyl  nitrite, 
and  erythrol  tetranitrate). 

Aromatic  spirits  of  ammonia  (oc- 
casionally used). 

Camphorated  oil  (subcutaneously) 
(occasionally  used). 

Squills  and  apocynum  (occasionally 
used). 

Adrenalin  (occasionally  used). 

Atropin  (occasionally  used). 

Theobromin  sodiosalicylate,  caffein 
sodiosalicylate. 

Calomel  (as  diuretic). 

Theocin. 

Caffein  (or  theobromin). 

Pilocarpin. 

Magnesium  sulphate.  ^ 


III.    Drugs  Used  to  Relieve  Pain. 

1.  Opium    (morphin,   heroin,    codein, 

Dover's  powder,  etc.). 

2.  Phenacetin  (usually  with  caffein). 


II.    Drugs    Used   to  Improve  Circulation 
and  Remove  (Edema. 

I.  Tincture  of  digitalis^  (prepared 
with  70%  alcohol  and  physio- 
logically tested). 

^  This  list  represents  only  the  usage  of  the  last  few  years.  Certain  drugs  used 
but  a  few  times,  or  for  purposes  chiefly  of  experiment,  are  omitted.  No  one  but 
myself  is  responsible  for  the  omissions  or  the  inclusions. 

2  Not  against  the  Treponema  but  against  the  products  of  the  disease  (gum- 
mata,  etc.) 

*  Iron  in  various  forms  is  also  used  for  other  kinds  of  anaemia  by  some  mem- 
bers of  the  staff. 

*  Certain  other  preparations  are  occasionally  used. 
^  In  saturated  solution,  as  derivative. 


28o 


CASE   HISTORIES   IN   MEDICINE. 


3- 

4- 
5- 
6. 

Sodium  salicylate  (also  aspirin  and 

novaspirin). 
Cocain. 
Acetanilid. 
Pyramidon. 

VI. 
I. 

2. 

3- 
4- 
5- 
6. 

IV.   Sedatives  and  Hypnotics. 

I. 

2. 

3- 
4- 
5- 
6. 

7- 
8. 

9- 

10. 

II. 

12. 

13- 
14. 

15- 
16. 

17- 

18. 

19- 


Veronal  (and  veronal  sodium). 

Trional.  VII. 

Bromid    (sodium    and    potassium 

chiefly).  i. 

Alcohol.  2. 

Chloral  (and  chloralamid).  3. 

Hyoscin  hydrobromate.  4. 

Paraldehyde  (occasionally  used). 
Sulphonal  (occasionally  used).  5. 

Amylene      hydrate      (occasionally        6. 

used)  7. 

Tincture  of  hyoscyamus  (occasion-        8. 

ally  used).  9. 

Apomorphine  (also  used  as  emetic).  10. 

II. 

V.    Laxatives  and  Purgatives.^ 

Sodium  phosphate.  12. 

Cascara.  13. 

Calomel.  14. 
Magnesium  sulphate. 
Aloes,  strychnin,  and  belladonna. 
Castor  oil.  i. 

Carlsbad  salts  (artificial).  2. 

Compound  cathartic  pill.  3. 

Compound  licorice  powder.  4. 

Elaterium.  5. 

Sodium  and  potassium  bitartrate.        6. 
(Seidlitz  powder).  7. 

Croton  oil.  8. 

Compound  jalap  powder.  9. 

Agar-agar.  10. 

Senna.  11. 

Rhubarb.  12. 

Podophyllum.  13. 

Vichy.  14. 

Magnesium  citrate.  15. 


Drugs  Used  to  Check  Diarrhoea  and 
Alleviate  Intestinal  Ulceration. 
Bismuth  salts. 

Camphor,  opium  and  tannin  pill. 
Tannigen  and  tannalbin. 
Silver  nitrate  (as  injection). 
Ipecac  (for  amoebic  dysentery). 
Salol. 

Drugs  Used  for  Supposed  Gastric 
Action. 
Sodic  bicarbonate.^ 
Lime  water. 

Dilute  hydrochloric  acid. 
Gentian  (often  with  nux  and  other 

bitters). 
Peppermint. 
Ginger. 
Red  pepper. 
Olive  oil. 
Orthoform. 
Milk    of    magnesia     (occasionally 

used). 
Tannate    of    orexin    (occasionally 

used). 
Beta-naphthol  (occasionally  used). 
Bismuth  salts  (occasionally  used). 
Resorcin  (occasionally  used). 

Miscellaneous. 
Arsenic  (Fowler's  solution). 
Ergot. 
Ox-bile. 
Oxygen. 
Urotropin. 
Thymol. 

Pelletierin,  aspidium,  etc. 
Hydrastis  (occasionally  used). 
Valerian  (occasionally  used). 
Asafoetida. 
Terpin  hydrate. 
Calcium  lactate. 
Sweet  spirits  of  nitre. 
Benzoate  of  sodium. 
Hypophosphites  (rarely). 


^  Arranged  approximately  in  order  of  the  frequency  of  their  use. 
2  Also  used  extensively  to  combat  acidosis  in  diabetes,  etc. 


COMMENTS. 


Comments. 


1.  On  the  specifics  I  have  Httle  to  say.  Some  would  in- 
clude here  the  use  of  ipecac  in  amoebic  dysentery,  of  pollantin 
in  pollen  fever,  of  urotropin  in  the  bacteriuria  of  typhoid  and 
antlvenene  In  snake  poisoning.  The  latter  is  omitted  because 
I  have  no  personal  experience  with  it;  the  others  because  I 
do  not  believe  their  action  strictly  specific. 

2.  In  the  digitalis  group,  I  believe  that  the  preparations 
called  "  digltalln,"  "  digalen,"  and  "  digltoxin  "  are  of  very 
limited  value  because  their  action  Is  so  uncertain.  The  same 
is  true  of  most  infusions  and  tinctures.  Standardized  tinc- 
tures (70%  alcohol)  and  standardized  solid  extracts  such  as 
diglpuratum  are  the  best  members  of  this  group. 

There  seems  to  me  no  good  reason  for  using  the  tincture 
of  strophanthus  or  any  strophanthus  preparation  except 
strophanthin,  since  this  Is  by  far  the  purest  and  most  reliable 
preparation.  Convallaria,  Apocynum,  and  Euonymus  should, 
I  think,  be  dropped  from  use.     The  same  Is  true  of  sparteln. 

Strychnin,  though  doubtless  used  too  much,  has  (In  my 
hands)  stood  the  test  of  time  as  the  best  heart  tonic  in  fevers 
and  in  neurasthenic  states.  The  nitrites  are  of  use  (In  my 
experience)  solely  in  angina  pectoris  and  spasmodic  dyspnoea. 
They  ought  not  to  be  used  for  lowering  arterial  tension  or  as 
a  cardiac  stimulant,  though  many  give  them  with  these  pur- 
poses In  view. 

Among  the  diuretics  I  have  found  diuretin  more  reliable 
than  theocin,  caffein,  or  any  other  officinal  diuretic.  It 
should  be  given  In  doses  larger  than  most  practitioners  use, 
15  to  30  grains  every  four  hours. 

Calomel  (2  or  3  grains  every  four  hours  for  three  days) 
is  a  most  valuable  diuretic,  far  too  much  neglected  and 
second  only  to  diuretin.  The  potassium  diuretics  are  too 
mild  to  be  worth  trying  in  dropsical  states.  Regarding 
magnesium  sulphate  as  a  remedy  for  dropsy,  it  should  be 
unnecessary  to  repeat  the  long  known  fact  that  only  in  con- 
centrated solution  is  it  of  value.     To  give  it  with  abundant 


282  CASE   HISTORIES   IN   MEDICINE. 

water  (as  for  constipation)  spoils  its  water-sucking  property 
in  dropsy. 

Pilocarpin  and  hot-air  baths  remove  practically  nothing  but 
water  and  are  therefore  properly  included  in  this  group. 

3.  Of  the  drugs  used  for  pain,  insomnia,  constipation,  and 
diarrhoea  I  have  nothing  special  to  say.  Of  the  drugs  supposed 
to  help  stomach  troubles  I  have  very  little  confidence  in  any 
but  the  alkalis  (such  as  sodic  bicarbonate)  which  relieve 
the  pain  of  peptic  ulcer  and  hyperchlorhydria,  carminatives 
(pepper,  ginger,  peppermint)  which  bring  up  "  wind,"  and 
bitters  which  stimulate  appetite. 

Pepsin  I  believe  to  be  useless  and  hydrochloric  acid  nearly 
so.  The  drugs  formerly  used  to  check  fermentation  are 
falling  into  disrepute,  since  we  have  begun  to  realize  that 
"  gas  "  and  "  wind  "  in  the  stomach  are  generally  due  to 
cribbing,  rarely  to  fermentation.  In  genuine  fermentation 
such  as  complicates  gastric  stasis  from  any  cause,  lavage  is 
far  better  than  any  drug. 

4.  I  have  rarely  been  sure  of  any  benefit  from  arsenic  in 
the  diseases  usually  treated  with  it  (chorea,  asthma,  leucaemia, 
pernicious  anaemia,  secondary  anaemia).  In  chlorosis  iron 
is  almost  invariably  better. 

Ergot's  great  usefulness  after  parturition  has  led  many  to 
use  it  to  check  haemorrhage  in  general.  But  ergot  stops 
bleeding  only  through  its  action  on  the  uterus,  and  other  drugs 
check  haemorrhage  only  when  we  can  apply  them  directly 
(adrenalin  in  nosebleed).  Pulmonary,  gastric,  intestinal  and 
vesical  bleeding  are  not  in  my  opinion  helped  by  any  internal 
medication. 

Oxygen  has  had  an  enormous  use  in  my  field  of  work. 
At  one  time  hardly  a  case  was  allowed  to  die  in  the  Massa- 
chusetts General  Hospital  without  an  attempt  to  stave  off 
death  through  "  inhalations"  of  oxygen.  I  have  never  seen 
it  do  any  good  except  in  a  single  case  of  moribund  phthisis; 
there  the  agonizing  dyspnoea  was  promptly  and  completely 
relieved.     In  pneumonia  it  is,  I  think,  valueless. 


INDEX. 

Page 

Abdominal  aneurism 241 

Abdominal  distention 76 

Abdominal  tumors ig6 

in  children 151 

Abdominal  relaxation,  how  secured 81 

Abolition  of  reflexes 56 

Abscess,  amoebic,  of  liver 46 

cervical 78,  191 

of  brain 49 

of  lung 84 

of  spleen 27 

Acne 89 

Acute  gastro-enteritis 104 

Adenoids 246 

Adolescence,  albuminuria  of 265 

Age,  in  myocardial  weakness 166 

Albuminuria,  causes  of 257 

of  adolescence 265 

Alcohol 56 

cause  of  fever 58 

Alcoholic  mania 204 

neuritis 204 

Alcoholism 58,  204 

Alkalies 282 

Alkaloids 277 

Altitude,  high,  in  secondary  ansemia 260 

Amoebic  abscess  of  liver 46 

Amoebic  dysentery 54 

Amyl  nitrate .      182 

Amyloid  kidney 1 53 

Anaemia 221 

aplastic 267 

arsenic  in 264 

high  altitude  in  secondary 260 

iron  in  secondary 260 

pernicious 159,  261,  269 

secondary 257 

Anaesthesia,  risks  of 29 

Aneurism 114,  181,  183,  191,  213,  214,  254,  272,  283 

abdominal 241 

Angina,  Ludwig's 78,  191 

pectoris 128,  178,  180 

283 


284  INDEX. 

Page 

Anti-syphilitic  treatment  in  tabes I97)  203 

Antivenene •" 281 

Aorta,  dynamic 212 

Aortitis,  syphilitic 4^ 

Apex,  impulse,  displacement  of 189 

Aphonia 183 

Aplastic  anaemia 267 

Apoplexy 5^ 

Appendicitis 72,  73.  133 

fear  of 104 

Apprehension I39>  230 

Arm,  swelling  of 253 

Arsenic 282 

in  anaemia 264 

Arteriosclerosis 128,  156,  165,  171,  184,  221,  234 

cerebral 193 

general 180 

(shock) 221 

with  involution  psychosis 238 

Arthritis,  atrophic 255 

Arythmia,  significance  of I37 

Asthma •      191 

bronchial 164,  191 

renal 164 

Asthmatic  tendency 171 

Athlete's  heart i74 

Atrophy ■ 207 

progressive  muscular 208 

Atrophic  arthritis 255 

Autointoxication : 225 

Babinski's  reaction •  •  •        51 

Bathing  in  typhoid 13 

Bed-sores • 14,  4° 

Biliary  colic 196 

Bismuth,  subcarbonate  of 30 

Blood  pressure,  measurement 194 

to  reduce 147 

Blood,  transfusion  of 29,  259 

Bradycardia 178 

Brain  abscess 49 

tumor 49.  227 

Bronchial  asthma 191 

breathing 187 

Bronchitis,  in  relation  to  disease  of  heart 171 

Bronchus,  empyema  rupturing  into  a 83 

Cachectic  purpura 257 

Caffein 281 

Calcic  oxalate 138 

Calomel 2 18 


INDEX.  285 

Page 

Cancer 117,  119,  120,  125,  139 

gastric 29,  97,  221 

hepatic 91 

of  colon 29 

of  duodenal  papilla iii 

of  hepatic  flexure  of  colon . 106 

of  lung 1 89 

of  pancreas. 123 

of  splenic  flexure  of  colon log 

Cardiac  attacks,  defective  conductivity  in 37 

hypertrophy  and  dilatation 149 

impulse,  absent 186 

impulse,  displaced 44 

lesion,  uncompensated 166 

overstrain 174 

stimulation  in  nephritis 148 

weakness  in  nephritis 146 

Carminatives 282 

Carotids,  significance  of  throbbing 163 

Catarrhal  jaundice 119,  120,  125 

Cellulitis 35 

Cerebral  arteriosclerosis 193 

embolism 169 

heemorrhage 171,  215,  228 

syphilis 51.  56,  228 

Cervical  abscess 191 

glands,  tuberculosis  of 79 

tumors '. 49 

Cheyne-Stokes  breathing 86 

Chicken-pox 89 

Chills,  causes  of 68 

Cholecystitis 133 

perforative 121 

Chronic  nephritis 35 

glomerulo-nephritis 145 

interstitial  nephritis 149 

Circulation,  drugs  used  to  improve 279 

Circumstances,  in  myocardial  weakness 167 

Cirrhosis,  anti-syphilitic  treatment  in 114 

Cirrhotic  liver 1 13,  124,  128 

Climate,  in  phthisis 28 

Coley's  toxins 188 

Colic,  biliary 196 

lead 196 

varieties  of 1 1 1 

Colitis,  ulcerative 154 

Colon,  cancer  of 27,  106,  109 

ulcer  of 29 

Coma 34.  56 

Common  colds 221 

Compression,  cerebral 56 


286  INDEX. 

Page 

Concussion,  cerebral 5° 

Congenital  cystic  kidney ^S^ 

Congestion,  pulmonary l8i 

Constipation ^39 

Constitutional  symptoms,  importance  of,  in  phthisis 25 

Contracted  stomach  in  gastric  ulcer 135 

Convalescence  in  phthisis 25 

Convallaria 281 

Coronary  sclerosis I77i  180 

Cough,  causes  of ^4 

Crile,  G.  W 245 

Crises,  vascular 52 

Cyanosis,  causes  of 7^ 

Cystic  kidney,  congenital 15^ 

Cystitis 37.  241 

Delirium 79 

Dementia  paralytica 205,  234 

Diabetes,  mellitus 56,  166,  246 

Diarrhoea,  drugs  used  to  check 280 

Diazo  reaction 44 

Diet • 126 

in  diabetes 248 

in  peptic  ulcer -• 30 

in  pneumonia I? 

in  typhoid 13 

Digestion,  in  phthisis 253 

Digipuratum 281 

Digitalis  group 281 

Dilatation  of  heart,  acute 163 

Diphtheria,  laryngeal 191 

Dipsomania 205 

Diseases  wrongly  diagnosed  as  "grippe" loi 

Distention,  gaseous 161 

Diuretics,  in  nephritis I47 

Diuretin 281 

Dosage 277 

Drugs,  having  specific  action 279 

in  neurosis 142 

in  phthisis 28 

in  traumatic  neurosis 216 

of  special  value  in  internal  medicine 279 

used  at  Mass.  General  Hospital 279 

used  for  gastric  action 280 

used  to  check  diarrhoea,  etc 280 

used  to  improve  circulation 279 

used  to  relieve  pain 279 

Duodenal  ulcer 1 14>  127 

Dynamic  aorta 212 

Dysentery,  amcebic ■ 54 

Dyspoena,  causes  of l°9 

inspiratory  and  expiratory 191 


INDEX.  287 

Page 

Eczema 89 

Effusion,  pleuritic 190 

Egophony 83 

Ehrlich,  Paul 274 

Elephantiasis 251 

Emaciation,  with  jaundice 97 

Embolism,  cerebral 169 

pulmonary 70 

Empyema 66 

rupturing  into  a  bronchus 83 

tuberculous 84 

Encephalopathy,  lead 49 

Endocarditis,  malignant 17,  37,  63,  68 

septic 258 

Enemata 29,  209 

Enteritis,  acute  gastro- 71 ,  104 

tuberculous 21 

Eosinophiles 79 

Epidemic  cerebrospinal  meningitis 86 

Epigastric  pain 128 

Epilepsy 56,  224 

Ergot 282 

Eruptions,  generalized  pustular / 89 

Erysipelas 36 

Examination,  methods  of 218 

sputum 44 

Exophthalmic  goitre 243 

Expectoration,  bloody 180 

Eyelids,  tremor  of 224 

Eyestrain 232,  246 

Face,  swelling  of 253 

Facies,  significance  of  peritoneal 129 

Family  history,  importance  in  phthisis 24 

Fatty  cirrhotic  liver 119 

Fecal  impaction 137 

Ferric  chlorid  test 224 

Fever,  causes  of  continued 22 

Fibroid,  uterine,  suppuration  in 81 

Flexner,  Simon .'  .• 275 

Flexner's  serum 87 

Foci  of  tuberculosis,  significance  of 25 

Forchheimer 244 

Functional  heart,  after  typhoid 160 

tachycardia 217 

Furunculosis 89 

Gall-bladder,  inflammation  of 121 

Gall-stones 116,  119,  124,  125,  133 

Gas  poisoning 56 

Gaseous  distention 161 


288  INDEX. 

Page 

Gastric  cancer 97,  221 

crisis 196,  202 

disease 203 

neurosis 135 

ulcer 114 

ulcer,  perforation  of -^^^  •  ■ ^^9'  ^33'  ^35 

Gastro-enteritis,  acute ^^^|L 71 

Generalized  tuberculosis ^^P^^t 43 

General  miliary  tuberculosis 39 

peritonitis 72 ,  76 

Gout 128 

Graves's  disease 54,  242 

Grippe 14 

diseases  wrongly  diagnosed  as loi 

Hands,  painless  swelling  of 149 

Hsematuria 144 

Haemorrhage,  cause  of 242 

cerebral .171,  228,  215 

from  oesophageal  varices 113 

pulmonary,  significance  of 25 

subcutaneous 258 

Headache,  causes  of 49 

Heart,  acute  dilatation  of 163 

athlete's 174 

bronchitis  in  relation  to  disease  of 171 

functional,  after  typhoid 160 

trouble,  neurotic  type 175 

Hepatic  cancer 91 

cirrhosis 128 

enlargement 97 

toxaemia 56 

Heredity  in  myocardial  weakness 166 

Hodgkins'  disease 272 

Homeopathic  principle 276 

Hookworm  disease - 54 

Hydrochloric  acid,  free loi 

Hydrothorax 190 

Hyperacidity,  urinal 232 

Hyperchlorhydria 197,  234 

Hypernephroma 151,  158 

Hypnotics 280 

Hysteria 56,  105,  223,  234 

Icterus 123 

Impetigo  contagiosa 89 

Impulse,  cardiac,  absent 186 

displacement  of  apex 189 

Income,  importance  in  phthisis 24 

Infections,  pyogenic 94 

Inguinal  neoplasm 251 


INDEX.  289 

Page 

Insomnia,  causes  of 58 

Intestinal  disease 203 

obstruction 12 1 ,  133 

Intracranial  trauma 1 1 

lodid,  administration  of  potassic 60 

Ipecac 281 

Iron 282 

in  secondary  anaemia .- 260 

Jackson,  J.  AI 244 

Jaundice,  catarrhal 119,  120,  125 

with  emaciation 97 

Jugular  pulsation ^ 178 

Kernig's  sign 52,  79 

Kidney,  amyloid 153 

congenital  cystic  disease  of 151,  156 

floating 133 

mobile  right 236 

tumors  of 151 

Knee-jerks 92 

reinforcement  of 204 

Laryngitis,  acute 191 

Laxatives 280 

Lead  neuritis 199 

colic 196 

encephalopathy 50 

Leg,  swelling  of 251 

Lenharz  treatment 31 

Leuccemia,  lymphoid 54,  271 

Leucocytosis 83 

Leucocyte  count,  significance  of 19 

Libman 65 

Liver,  amcEbic  abscess  of 46 

cirrhotic 113,  119 

smooth 119,  204 

syphilis  of 124 

Ludwig's  angina 78,  191 

Lumbar  puncture 40 

Lung,  abscess  of 84 

amount  involved 25 

cancer  of 187,  189 

signs  in  phthisis 24 

tuberculosis  of 79 

Lymphangitis ^ 251 

Lymphoid  leucsemia 54,  271 

Macular  rash 59 

Magnesium  sulphate 281 

Malaria 19,  22,  49,  94,  129,  197,  246 


\y 


290  INDEX. 

Page 

Malignant  disease  of  the  lung 187 

of  thymus  gland 253 

Malignant  endocarditis 37>  63,  68 

Malingering 243 

Mania,  alcoholic 204 

A'lanipulation  in  angina  pectoris 182 

Massage,  dangers  of  in  phlebitis 72 

Masturbation 246 

effects  of 232 

Maternal  anxiety 232 

Mayo  clinic 98,  107 

Meat,  in  nephritis I47 

Mediastinal  tumor 272 

Meningismus 50 

Meningitis 34-  43-  52,  87,  105,  225 

epidemic  cerebrospinal 86 

tuberculous 48 ,  79 

Mercury,  administration  of 60 

Micturition,  causes  of  frequent 232,  262 

significance  of  nocturnal 149 

Migraine 145 

Mitral  stenosis 169 

Mode  of  onset,  significance  of 51 

Morphia,  producing  fecal  movement .- 109 

Mortality  in  appendicitis 73 

Moving  sick  patients 37 

Mucus  in  stomach  content 1 02 

Murmurs,  causes  of  presystolic 68 

Muscular  irritability 207 

tenderness 44 

weakness 200 

Myocardial  weakness 163,  165,  172,  174,  178 

Myositis 201 

Myxcedema 236,  238 

Neoplasm,  inguinal 251 

Nephritis 54>  105,  221,  226 

acute 16 

chronic 35 

chronic  glomerulo- I45>  I75 

chronic  interstitial 149,  i6r 

puerperal 258 

Neurasthenia 54.  234 

Neuritis 196,  204,  207 

lead 199 

Neurosis 1 35 

fear I39 

traumatic 214 

Neurotic  vomiting 209 

Night  sweats 64 

Nitroglycerin 1 82 

Nutrition  in  phthisis 27 


INDEX.  291 

Page 

Obesity 238 

Obstruction,  intestinal 121,  133 

Occupation  in  phthisis 27 

(Edema 242 

pulmonary 163,  178 

Odors  in  the  breath 169 

Oliguria,  causes  of 72 

Onset,  significance  of  mode  of ' 5^ 

Opium  poisoning 56 

Order  of  symptoms,  significance  of 34 

Orthopnoea 189 

Otitis  media 1 9 

Overeating 131 

Overstrain,  cardiac I74 

Pain,  after  meals 131 

epigastric 128 

in  chest 19 

in  hepatic  enlargement 119 

in  left  axilla 18 

in  pulmonary  diseases 185 

in  sternum 191 

in  trunk  and  limbs 92 

paroxysmal  epigastric 234 

substernal 131 

thoracic,  drugs  used  to  relieve 279 

worse  at  night 271 

Pallor,  significance  of 246 

Pancreas,  cancer  of 123 

Pancreatitis I33 

Paralysis,  types  of  facial 169 

Parotitis 16 

Pectoral  muscle,  irritability  of 44 

Pelvic  sepsis 209 

Pepsin 282 

Peptic  ulcer 121,  122,  133 

diet  in 32 

duration  of .  30 

medical  treatment 31 

operation  in 30 

relapse  in 30 

transformed  into  cancer 30 

Perforated  gastric  ulcer 29 

Perforative  cholecystitis 121 

Periostitis 42 

Peritoneal  facics,  significance  of 129 

Peritonitis Ji-  104 

general 72,76 

tuberculous 18,  64 

Pernicious  anaemia 261 ,  269 

Phlebitis 251 

left  femoral 7^ 


292  INDEX. 

Page 

Phthisis 21,  27,  54,  84,  241,  243 

climate  in 26 

cure  of 26 

drugs  in 28 

nutrition  in 27 

occupation  in 27 

Pilocarpin 282 

Placebos 275 

dropped  from  pharmacopoeia 276 

Pleuritic  eflfusion 190 

Plumbism 72,  129,  130 

Pneumohydrothorax 185 

Pneumonia 15,  58,  164,  188 

central 191 

diet  in 17 

hypostatic 181 

unresolved 84 

Poisoning,  gas 56 

opium 56 

ptomaine 87 

Pollantin 281 

Polypharmacy 277 

Potassic  iodid,  administration  of 60 

Prsevertebral  glands,  sarcoma  of 240 

Pressure,  measurement  of  blood 19+ 

Prostate,  irritable 143 

Psychoneurosis 193 

Psychosis,  involution,  with  arteriosclerosis 238 

Ptomaine  poisoning 87 

Puerperal  nephritis 258 

Pulmonary  congestion l8l 

embolism "Jo 

haemorrhage,  significance  of 25 

oedema 1 63 

signs,  importance  of 44 

Pulmonic  second  sound,  accentuated 187 

Pulsation,  epigastric 212 

jugular 178 

significance  of  cervical 163 

Puncture,  lumbar 40 

Pupils,  indications  of 49 

Purgatives 280 

Purpura,  cachectic •. 257 

Pyogenic  infections 94 

Pyrexia,  causes  of 106 

Rash,  macular 59 

Rattle  in  throat,  significance  of 163 

Reflexes,  abolition  of 5^ 

Relapse  in  peptic  ulcer 30 

Respiration,  causes  of  diminished 149 

significance  of  sterterous 171 


INDEX.  293 

Page 

Rest  cure 142 

Retinal  changes,  in  nephritis 146 

Retroversion  of  uterus 209 

Rheumatism,  diseases  diagnosed  as 200 

Risks  of  anaesthesia 29 

Rogers-Beebe  serum 244 

Rose  spots 68 

Salvarsan " 62,  274 

Sarcoma  of  praevertebral  glands 240 

Sclerosis,  coronary 172,  177,  180 

Secondary  anaemia 257 

Sectarianism  in  medicine 277 

Sedatives 280 

Sepsis,  acute 251 

general 22 

pelvic 209 

streptococcous 34 

urinary *. 36 

Septicaemia 64 

Septic  endocarditis 258 

Serum,  Flexner's 87 

Rogers-Beebe 244 

Sodic  bicarbonate 32,  282 

Spartein 281 

Specific  action,  drugs  having 279,  281 

Spleen,  abscess  of 29 

Splenic  enlargement,  causes  of 114 

Spondylitis 240 

Sputa,  significance  of  bloody 185 

Sputum  examination 44 

Starvation 209 

Sternum,  pain  in 191 

Stokes- Adams  syndrome 177 

Stomach,  cancer  of 29 

'  contracted,  in  gastric  ulcer 136 

trouble  in  elderly  persons 128 

tube 129 

ulcer  of 29 

Stools,  causes  of  tarry 114 

Strabismus,  causes  of 39 

Streptococcous  sepsis 34 

Strophanthin 281 

Strychnin 281 

Sunstroke 5^ 

Supinator  longus  test 200 

Symptoms,  significance  of  order  of 34 

afternoon 224 

Syncope 5^ 

Syphilis 20,  54,  58,  98,  119,  120,  172 

cerebral 51,  56,  228 


294  INDEX. 

Page 

Syphilis,  general  condition  in 59 

of  liver • 124 

Syphilitic  aortitis 41 

Tabes 129,  133,  196,  202,  205,  208,  234 

Tachycardia,  functional 217 

Temperament  in  phthisis 24 

Temperature,  causes  of  subnormal 106 

Tenderness,  causes  of  muscular 207 

other  types 207 

over  shins 238 

Tertian  malaria 94 

Theocin 281 

Thrombosis 68 

venous 80 

Thymus  gland,  malignant  disease  of 253 

Tongue,  significance  of,  in  disease 107 

Towns-Lambert  treatment 206 

Toxaemia,  hepatic 56 

Toxins,  Coley's 188 

Tracheitis 191 

Transfusion  of  blood 29,  259 

Trauma,  intracranial 13 

Traumatic  neurosis : 214 

Tremor  of  eyelids 224 

Trichiniasis 91 

Tuberculosis 15,  20,  43,  64,  154,  188,  221 

foci,  significance  of 25 

general  miliary » 39 

generalized 43 

medical  or  surgical  treatment  in '. 20 

of  lung,  meninges,  and  cervical  glands 79 

Tuberculous  empyema 84 

enteritis 23 

meningitis 48 

peritonitis 64 

Tumors,  abdominal 156 

abdominal,  in  children 151 

cerebral 49,  227 

cervical 49 

mediastinal 272 

renal 151 

Typhoid 13,  19,  23,  45,  52,  58,  64,  83 

bathing  in 15 

diet  in. 15 

Ulcer,  duodenal 114,  121,  122,  127 

gastric 29,  II4,  197 

gastric,  perforation 27,  129,  133,  135 

of  colon 29 

Ulceration,  drugs  used  to  alleviate  intestinal 280 


INDEX.  295 

Page 

Ulcerative  colitis 154 

Uraemia 52,  56,  81,  133,  145,  228 

Urinal  hyperacidity 232 

Urinary  sepsis 36 

Urine,  causes  of  sugar  in 165 

of  low  specific  gravity 269 

Urotropin 281 

Uterine  fibroid,  suppuration  in .-  .  • 81 

Uterus,  retroversion  of 209 

Varicella 89 

Varices,  oesophageal,  haemorrhage  from 113 

Varicocele,  relation  to  sexual  excesses 212 

Varicose  veins 205 

Variola 89 

Vascular  crises 52 

Vomiting,  causes  of  stercoraceous 107 

neurotic 209 

of  greenish  fluid 196 

Wassermann  reaction 59 

Weakness 163 

muscular,  causes  of 200 

myocardial 165,  178 

Weight,  cause  of  loss  of 178 

increase  in 180 

Wheezing 191 

"Wiring"  in  aneurism ' 184 

X-ray  exposure 272 


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